
ciass_fiilys!2_ 

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Copyright )J° 



COPyRIGHT DEPOSm 



TREATMENT 



OF THE 



DISEASES OF CHILDREN 



BY 

CHARLES GILMORE KERLEY 

Professor of Diseases of Children in the New York Polyclinic Medical School and 
Hospital ; Attending Physician to the New York Infant Asylum and Maternity ; 
Assistant Attending Physician to the Babies' Hospital; Consulting Physi- 
cian to^the Sevilla Home for Girls and to the New York Home for 
Destitute and Crippled Children ; Consulting Pediatrist to the 
Greenwich (Connecticut) Hospital 



SECOND EDITION, REVISED 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1909 






Set up, electrotyped, printed, and copyrighted June, 1907. Reprinted November, 1907, 
and January, 1908. Revised, reprinted and recopyrighted April, 1909. 



Copyright, 1909, by W. B. Saunders Company 



PRINTED IN AMERICA 



PRESS O F 

W. B. SAUNDERS C O M PA N ' 

PHILADELPHIA 



LIBRARY of CONGRESS 
Two CoDies Received 

APR 29 1809 

CLASS fiC AXc No. 



TO 
MY PRACTITIONER STUDENTS 

PAST AND PRESENT 



NEW YORK POLYCLINIC MEDICAL SCHOOL AND HOSPITAL, 

AT WHOSE SUGGESTION 

THIS WORK HAS BEEN PREPARED 



PREFACE TO THE SECOND EDITION 



The reception of this work by the medical pubHc and the 
reviewers has been most gratifying. In this second edition, an 
attempt to supply the practitioner a volume of increased utility 
has been the aim of the author. 

I am indebted to Dr. Ro3^al S. Haynes, Dr. Ward B. Hoag, 
and Dr. Hugh C. Thompson for their valuable assistance in the 
preparation of the work. 

9 



PREFACE 



This work has been prepared for the general practitioner of 
medicine. It has not been written with a view to supplying the 
needs of either the specialist in children's diseases or the under- 
graduate student. The possibilities of therapeutic measures in the 
treatment of children have greatly increased during the past decade ; 
and the author's effort in this volume has been to present to the 
physician in active general practice, modern miethods of management 
in greater detail than has been attempted by the valuable books 
already on the market. The means and methods suggested herein 
are not drawn from the literature, but from experience based upon a 
somewhat extensive application of the principles evolved by the 
author in private and hospital practice. This book is offered, there- 
fore, with the hope that it may be of service to other physicians in 
caring for an important group of their patients. 

The author wishes to acknowledge his indebtedness to Dr. James 
F. McKernon for suggestions in the chapters on the diseases of the 
ear; to Dr. Thomas L. Bennett for suggestions in the chapter on 
Anesthetics; to Dr. N. Curtice Holt for the revision of the proof 
sheets, and to Dr. Royal Storrs Haynes for the arrangement of the 
index and his valuable assistance in the preparation of the chapter on 
Drugs and Drug Dosage. 



CONTENTS 



PAGE 

General Considerations 17 

Therapeutics in Children, 17— Clothing and Additional Requirements 
for the Expected Baby, 19 — The Young Mother, 21 — The Nursery 
Maid, 22 — The Nursing-bottle and Nipple, 23 — The Nursery, 24 — 
Baskets for Early Exercises, 25 — Care of Stump of Umbilical Cord, 26 — ■ 
Crying, 26^Sleep, 27 — Kissing, 28 — Baths, 29 — Weight, 31 — Height, 34 
— Teeth, 35 — Days to Go Out of Doors; Indoor Airing, 37 — Exercise 
Pen, 37 — First Examination of Patient, 39 — Written Directions, 40 — 
Treatment of Individual, 42 — Necessity of Method in the Management 
of Children, 42 — The Sick-room, 43. 

The New-born 45 

Premature and Congenitally Weak Infants, 45 — Asphyxia, 48 — Sepsis, 
49 — Cephalhematoma, 50 — Icterus Neonatorum, 50 — Umbilical Polyp, 
51 — Atelectasis, 51 — Mastitis, 52 — Umbilical Granuloma, 53 — Hemor- 
rhagic Diseases, 53 — Tetanus Neonatorum, 56. 

Nutrition and Growth 57 

General Properties of Foods, 61 — Human Milk, 64 — Maternal Nursing, 
66 — Cracked and Fissured Nipples, 78 — Caking of the Breasts, 79 — 
Depressed Nipples, 79 — Acute and Suppurative Mastitis in the Mother, 
80 — The Wet Nurse, 80 — Substitute Breast Feeding; Artificial Feeding, 
82 — Cream, iii — Difficult Feeding Cases, 112 — Sterilization and 
Pasteurization of Milk, 115 — Condensed Milk, 118 — Peptonized Milk, 
119 — Feeding of Buttermilk, Sour Milk, Fermented Milk, 120 — Milk 
for Traveling, 122 — The Proprietary Foods, 123 — Cereal Gruels; Starch- 
feeding, 125 — Food Formulas, 129 — Habitual Loss of Appetite, 131 — 
Common Errors in Feeding, 133 — Diet from the First to the Sixth Year, 
134 — Diet after the Sixth Year, 138 — How the Child Should be Fed, 138 
— Diet during Illness, 139 — Gavage, 140 — Substitutes for Stomach- 
feeding, 144 — The Delicate Child, 148 — Marasmus; Athrepsia; Infantile 
Atrophy, 156 — Malnutrition in Infants, 162 — Tardy Malnutrition, 164. 

Essentials in the Care ot Acute Illness 166 

Gastro-enteric Diseases 171 

Acute Intestinal Indigestion, 171 — Persistent Intestinal Indigestion, 
172 — Persistent Intestinal Indigestion in Older Children, 173 — Colic, 
175 — Bowel Function, 177 — Vomiting, 187 — Acute Gastritis and Acute 
Gastric Indigestion, 188 — :Chronic Gastric Indigestion; Chronic Gas- 
tritis, 190 — Lavage; Stomach-washing, 191 — Hemorrhage from the 
Stomach; Vomiting of Blood, 194 — Dilatation of the Stomach, 194 — 
Ulceration of the Stomach, 195 — Congenital Pyloric Stenosis, 196 — 
Prevention of Acute Intestinal Diseases of Summer, 197 — Acute Gastro- 
enteric Infection; Cholera Infantum; Gastro-enteric Intoxication, 202 — 
Acute Enteric Infection, 208 — Lactic Acid Bacillus in the Treatment of 
Acute Intestinal Infections, 211 — Acute Ileocolitis, 2ii^Chronic Ileo- 
colitis, 216 — Mucous Colitis, 218 — Colon Irrigation, 219 — Intestinal Ob- 
struction, 221 — Appendicitis, 222 — Intussusception, 223 — Inflammation 
of the Anus, 225 — Fissure of the Anus, 225 — The Intestinal Parasites, 
226 — Prolapse of the Anus and Rectum, 228 — Ischiorectal Abscess, 230 
— Hemorrhoids, 230 — Rectal Polypus, 231 — Incontinence of Feces, 231. 

The Mouth, Throat, and Nose 232 

Stomatitis, 232 — Sprue, 235 — Thrush; Myotic Stomatitis, 235 — Can- 
crum Oris; Noma, 236 — Bednar's Aphthae, 237 — Fissures of the Lips, 

13 



14 CONTENTS 

PAGE 

238 — Ulcerations and Fissures at the Angle of the Mouth, 238- — Ulcer 
of the Frenum of the Tongue, 238 — Geographic Tongue, 239 — Tongue- 
tie, 239. 

Diseases of the Respiratory Tract 240 

Taking Cold, 240 — Acute Rhinitis (Coryza; Snuffles; Cold in the Head), 
241 — Chronic Rhinitis; Nasal Catarrh, 244 — Recurrent Coryza and 
Angina, 245 — Nasal Hemorrhage, 246 — ^Throat Examination, 246 — 
Faucitis, 247 — Pharyngitis, 248 — Tonsillitis, 248 — Hypertrophied Ton- 
sils, 252 — Peritonsillar Abscess; Quinsy, 252 — Retropharyngeal Abscess; 
Suppurative Retropharyngeal Adenitis, 254 — Retropharyngeal Abscess 
(Tuberculous) ; Caries of the Cervical Vertebrae, 258 — Irrigation of the 
Throat, 258 — Acute Catarrhal Laryngitis, Spasmodic Croup, 259 — 
Laryngismus Stridulus, 264 — Traumatic Laryngitis, 266 — Laryngeal 
Obstruction, 267 — Foreign Bodies in the Larynx, 267 — Persistent Cough, 
268 — Bronchitis, 270 — Recurrent Bronchitis, 274 — Bronchial Asthma, 
276 — Bronchopneumonia; Catarrhal Pneumonia, 280 — Lobar Pneu- 
monia, 286 — Primary Pleurisy, 292 — Secondary Pleurisy, 293 — Primary 
Tuberculous Pleurisy, 294 — Empyema, 294 — Double Empyema, 297 — 
Empyema Necessitatis, 298 — Pulmonary Tuberculosis, 298 — Bronchi- 
ectasis, 301. , 

Diseases oe the Heart 303 

Pericarditis, 303 — Acute Endocarditis, 304 — Malignant Endocarditis, 
307 — Myocarditis, 307 — Chronic Valvular Disease of the Heart, 310 
— Congenital Heart Disease, 313 — Abuse of Heart Stimulants, 313. 

Contagious Diseases. 314 

. Care to be Exercised by the Physician in Visiting Contagious Diseases, 
3i4^Quarantine, 314 — Diphtheria, 316 — Intubation, 324- — Scarlet 
Fever, 328 — Whooping-cough; Pertussis, 336 — ^Measles, 344 — Chicken- 
pox; Varicella, 346 — German Measles; Rubella, 347 — Mumps; Epi- 
demic Parotitis, 348. 

The Urine 349 

Difficult and Painful Urination, 350 — Retention and Suppression of 
Urine, 350 — Incontinence of Urine; Bed-wetting; Enuresis, 352 — 
Albuminuria, 356 — Acute Nephritis, 357 — Chronic Diffuse Nephritis, 
362 — Glycosuria, 365 — Diabetes Insipidus; Polyuria, 366 — Diabetes 
Mellitus, 366 — Vesical Calculus; Stone in the Bladder, 367 — Cystitis, 
367 — Acute Pyelitis, 368. 

The Male Genitals 369 

Phimosis, 369 — Paraphimosis, 370— Balanitis, 370 — Circumcision, 371 — 
Gonorrhea in the Male, 372 — Orchitis, 372 — Hydrocele, 372 — Unde- 
scended Testicle, 373. 

The Female Genitals 374 

Simple Vulvovaginitis, 374 — Gonorrheal Vulvovaginitis, 374. 

Nervous Disorders 376 

Headache, 376 — Hysteria, 376 — Infantile Convulsions, 380 — Night- 
terrors, 382 — Gyrospasm; Spasmus Nutans, 382 — Tetany, 383 — 
Chorea; St. Vitus' Dance, 384 — Habit Spasm, 387 — Epilepsy, 388 — 
Acute Simple Meningitis, 390 — Cerebrospinal Meningitis, 392 — Tuber- 
cular Meningitis, 395 — Lumbar Puncture, 396 — Chronic Internal Hydro- 
cephalus, 397 — Acute Anterior Poliomyelitis; Infantile Paralysis, 398 — 
Diphtheritic Paralysis, 399 — Multiple Neuritis, 401 — Facial Paralysis, 
402—Cerebral Palsies, 403 — Idiocy, 404 — Erb's Palsy; Obstetric Par- 
alysis, 406 — Hiccough, 407 — Angioneurotic Edema, 407. 

Syphilis 409 

Primary Congenital Syphilis, 409 — Tardy Hereditary Syphilis, 411 — 
Tardy Malnutrition of Syphilitic Origin, 412. 



CONTENTS 15 

•^ PAGE 

Deformities 415 

Inguinal Hernia, 415 — Umbilical Hernia, 416 — Ventral Hernia, 417 — 
Spina Bifida, 417 — Harelip, 418 — Hematoma of the Sternocleidomas- 
toid Muscle, 418— Cleft Palate, 418. 

Diseases of the Skin 420 

Eczema, 420 — Urticaria; Hives; Nettle-rash, 429 — Impetigo Conta- 
giosa, 431 — Pemphigus, 431 — Erythema Nodosum, 432 — Erythema 
Multiforme, 433— Rhus Poisoning; Ivy Poison, 433 — Furunculosis; 
Boils, 434— Scabies; Itch, 435— Bed-sores; Decubitis, 435— Pediculi, 
436 — Tinea Tonsurans; Ring-worm of the Scalp, 437 — Tinea Circinata, 
438 — Miliaria; Prickly Heat, 439. 

Diseases of the Ear 44^ 

Earache, 440 — Acute Otitis, 440 — Deafness, 444 — Chronic Suppurative 
Otitis, 444 — Mastoiditis, 445. 

Glandular Diseases 446 

Acute Adenitis, 446 — Persistent Adenitis, 447 — Adenoids, 448 — Retro- 
pharyngeal Adenitis, 451 — Tuberculous Adenitis, 452. 

Heredity and Environment 453 

Habits, 454 — Masturbation, 455. 

Constitutional Disorders 459 

Icterus; Obstructive Jaundice, 459 — Obesity, 460 — The Anemias of 
Infancy and Childhood, 460 — Rachitis, 463 — Scorbutus; Scurvy, 467 — 
Sporadic Cretinism; Infantile Myxedema, 467 — Status Lymphaticus, 
471 — Purpura, 471 — Hemophilia, 472. 

Infectious Fevers 474 

Influenza, 474 — Malaria, 476 — Typhoid Fever, 478 — Erysipelas, 483 — 
Rheumatism, 485 — Peliosis Rheumatica, 490- — Acute General Peritoni- 
tis, 491 — Tuberculous Peritonitis, 491 — Dactylitis, 492 — Tuberculous 
Bone Disease, 493 — Glandular Fever, 493 — Cyclic Vomiting, 494. 

Temperature in Children 496 

Obscure Elevations of Temperature, 499 — Cold Sponging in Fever, 502 — 
The Cool Pack, 503 — Bathing the Sick, 505. 

Vaccination 506 

Instructions for the Summer 509 

Rules for the Care of Dispensary Infants and Young Children during 
the Summer, 511 — Summer Resorts, 513. 

Therapeutic Measures 515 

Counterirritants, 515 — Anesthetics, 516 — Colon Flushing, 518 — Alco- 
hol, 519 — Heat as a Therapeutic A ent, 520 — Cold as a Therapeutic 
Agent, 521 — The Therapeutic Value of Climate, 522 — Promiscuous Use 
of Drugs by the Family, 523 — Unpalatable and Nauseating Drugs, 524. 

Vaccine Therapy 527 

New Diagnostic Methods, 532. 

Gymnastic Therapeutics 534 

Rules, 534 — Posture and Breathing, 537— Breathing, 542 — Flat Chest, • 
546 — Kyphosis, 547 — Scoliosis, 551 — Congenital Ataxias, 556 — Ante- 
rior Poliomyelitis, 569 — Constipation, 571 — Flat-foot, 573. 

Drugs and Drug Dosage 575 

For Internal Use, 575— For External Use, 588. 



Index. 



593 



THE TREATMENT 

OF THE 

DISEASES OF CHILDREN 



GENERAL CONSIDERATIONS 

THERAPEUTICS IN CHILDREN 

If I were asked what I considered the chief requisite for the 
successful practice of pediatrics I would answer : The education 
of the mother. It is impossible to do even fairly good work in 
diseases of children without proper home co-operation. A direc- 
tion is never followed out as well as when the reason for it is 
understood. 

^luch of our beneficial results is due to the therapeutic influences 
of remedies outside of the realm of drugs. Thus, diet, fresh air, 
cold, heat, massage, electricity, climate — all are important therapeu- 
tic agents in the diseases of children. Successful therapy in children 
involves an understanding, a knowledge of detail, greater perhaps than 
in any other line of medical work. It not infrequently is an absence of 
such knowledge on the part of medical men which explains a great 
deal of the therapeutic doubt existing at the present time. Thera- 
peutic nihilism, as far as pediatrics is concerned, means ignorance and 
incompetency. The time when the physician can make a diagnosis, 
and cease his interest in the treatment of the case is past. One of 
two things will happen in the absence of interest or ability on the 
part of the physician. The faith of humanity in curative agents is 
remarkable, and when the desired end is not reached by the first 
physician, some other physician is called ; and when he fails, the next 
resort usually is the charlatan and the proprietary and patent 
medicines. 

The prosperity of the irregular schools of various cults and 
" sciences" supposedly healing in character, and the consumption by 
the people of millions of dollars' worth of useless proprietary and 
patent drugs are to be attributed in a large degree to an indifferent 
application of therapeutic measures on the part of otherwise well 
qualified medical men. A few great teachers of medicine have 
2 17 



1 8 GENERAL CONSIDERATIONS 

done an incalculable amount of harm by precept and example in 
their attitude toward therapeutics. Because they were or are 
unable successfully to treat disease they assume that it cannot be 
done. Thus therapeutic doubt, using the term therapeutics in the 
broad sense, has been in the past boasted of by men considered 
clever. Text-books on pediatrics are not without fault in encourag- 
ing careless practice, with necessarily an absence of favorable 
results, especially when they state that "treatment is along sup- 
portive lines." What constitutes "supportive lines" in a given 
case? How is the practitioner to know the author's mind? Or, 
again, perhaps it is stated that "free stimulation" is necessary. 
Stimulation how, when, why, and by what means is what must be 
known, in order to achieve satisfactory results. "Treatment ac- 
cording to the indications of the case" does not help a puzzled 
physician to any great extent. "Treatment along the same lines 
as in adults," adds no illumination when a desperately sick child 
is the patient, and moreover is faulty teaching, for the reason that 
the treatment in such instances should never be the same as in 
adults. An infant or young child can never be treated the same 
as an adult, either by drugs or other measures, unless we wish 
more thoroughly to convince ourselves of the uselessness of thera- 
peutic measures. In order to practise therapeutics successfully in 
children the methods of the physician must be flexible and adaptable. 
Children vary greatly in their physical and mental equipment, much 
more than do adults. The practice of pediatrics is necessarily 
difficult, for every case has to be studied from its own standpoint. 
The physician who invariably treats all his cases alike will never do 
the highest class of work with children. The man, for example, 
who feeds all his difficult feeding cases after one rule or pattern will 
be sure to have some other practitioner get his failures, which will 
not be few. A source of disappointment to physicians, particularly 
in the treatment of young infants and children, is in the disorders 
of nutrition. A tremendous amount of patience is required in 
dealing with such cases, and the absence of prompt results is one of 
the difficult features he has to contend with in his relations with the 
family. There is, further, a distinction to be made as to what con- 
stitutes good results. If the infant develops into a strong child, 
we may chronicle our results as satisfactory even though a year was 
required before the condition of the patient was satisfactory. To 
cause a malnutrition baby weighing only eight pounds at six months, 
with marked milk incapacity, to show rapid growth by any method 
of artificial feeding is unusual, and our results are good if he gains but 
little during the first few weeks. 

Chronic colitis, tardy malnutrition, or nephritis may require 
months and years for correcting and yet furnish satisfactory results. 
In therapeutics in infants and children, particularly as regards the 



CLOTHING, HTC, FOR THE EXPECTED BABY I9 

use of drugs, two points are to be kept in mind — the benefit hoped 
for and the possible harm that may result. A great deal of judgment 
must be used in the selection of remedies and the means of using 
them lest our best intentions result disadvantageously to the patient. 
Thus, in bronchitis and in bronchopneumonia the ammonium salts 
are often given in combination with heavy syrups such as tolu and 
wild cherry, both possessing little or no expectorant value, but they 
possess the property of interfering seriously with the patient's diges- 
tion. Doubtless alcohol used indiscriminately is, on the whole, 
productive of more harm than benefit, largely through disturbing the 
digestion. Digitalis, the salicylates, and the potassium and sodium 
salts are all to be used with judgment as to method and time of 
administration or they will do more harm than good. A point 
never to be lost sight of in the treatment of diseases of children 
is the desirability of keeping the gastro-enteric tract in the best 
possible condition. In children there are other factors also that 
bear upon the case that tend toward good or evil. The most careful 
diet and the best selected medication are of little value if the patient 
is overclad, kept in a superheated room with anxious, oftentimes 
nervously exhausted persons in constant attendance, with the dis- 
turbance to the patient which such attendance entails. However, 
it must be remembered that absence of proper detail and good 
judgment with resulting failures is no argument against the value 
of therapeutic measures, although it often furnishes the evidence 
upon which the argument is based. Much may be accomplished, by 
means of prophylaxis, in lowering the mortality in children under 
five 3^ears of age. In these the educated mother's aid is invaluable. 
She will lay aside prejudices and unfavorable family influences when 
a physician's direction appeals to her reason. Marasmus, malnu- 
trition, and the intestinal diseases of summer, which directly or 
indirectly are the cause of thousands of deaths yearly, are to a 
large degree preventable if the right step is taken at the right time, 
through the early appreciation of danger-signals on the part of both 
the physician and the mother. 



CLOTHING AND ADDITIONAL REQUIREMENTS 
FOR THE EXPECTED BABY 

The physician should instruct the young woman who for the 
first time expects to become a mother as to the necessary clothing 
and toilet articles which she will need for her convenience in the 
care of the child. A basket in which all the toilet necessities for 
the baby may be kept together will be found a great convenience 
when the time for their use arrives. 

The basket should be provided with a good-sized pin-cushion 
and pins ; 



20 GENERAL CONSIDERATIONS 

Puff-box and puff; 

Soap-box, containing castile soap; 

Infant's hair-brush and fine comb; 

Eight ounces of a saturated solution of boric acid for mouth 
and eyes; 

One-haff pound of absorbent cotton; 

A package of wooden toothpicks; 

A flexible tube of white vaselin; 

A bath thermometer; 

One yard of plain sterile gauze; 

Plenty of soft old linen ; 

Six of the best baby towels ; 

A white eiderdown blanket one and one-half yards long ; 

One pair of small scissors ; 

A package of nickel-plated safety-pins (three sizes) ; 
Clothing to be provided : 

Forty-eight cotton diapers, made from birdseye cotton diaper; 
two sizes are necessary: 

(a) Three pieces 20 inches wide. 

(b) Three pieces 22 inches wide. 

One yard of white flannel for belly-bands. Leave the piece as 
it is, to be used by the nurse as required. After the sixth week, 
knitted bands with shoulder-straps are preferable. 

Four second-size silk-and-wool shirts; 

Six pinning blankets made of white flannel with cotton bands; 

Three flannel shirts; 

Three eiderdown wrappers ; 

Three Cashmere sacques ; 

Three bath aprons of shaker flannel for the mother or nurse, to 
be used to cover the baby after he is taken from the bath ; 

Three pads, each one yard square, and three each one-half yard 
square. These are necessary for the crib and lap. 

Diapers. — Diapers are best made from soft light-weight goods 
which absorb readily. Birdseye cotton diapers are satisfactory. 
The diaper should be removed when soiled and placed in a covered 
pail containing a carbonate of sodium solution, one ounce to two 
gallons of water, or in carboHc acid solution i : 100. Before using, 
whether soiled with urine or feces, they should be boiled and washed 
with plain Castile soap. Several rinsings will be required before the 
napkins are dried, so as to remove the soda and soap. They should 
not be dried in the nursery. The rubber protector used as a cover 
for the napkin should be used only during cold weather and when 
the child is out of doors. After changing the diaper the mother or 
nurse must immediately scrub her hands and nails thoroughly with 
hot water, soap, and brush. A diaper washer unique in design and 
satisfactory in its work is the washer known in the market as Cunnee's 



THE YOUNG MOTHER 21 

sanitary napkin washer.^ This is so constructed that it may be at- 
tached to the hot-water pipe of any bath-room. It does away with 
the disagreeable features of diaper washing by hand and lessens the 
dangers of contamination of food apparatus and food at the hands 
of the nurse. 

THE YOUNG MOTHER 

In order to achieve success in pediatrics, the physician requires 
the active cooperation of trained helpers. The more capable the 
mother and nurse, the greater the success that will crown his labors 
when children are his patients. The physician, therefore, should 
undertake the instruction of the young mother in the rudiments of 
the child's care. In my own experience, the intelligent mother, 
regardless of her station of life, has proved a most satisfactory 
pupil. Endowed with good common sense, with her powers for 
reasoning well developed, and possessing an ability to appreciate 
scientific principles, her usefulness as a mother is thus increased 
tenfold. 

In order to secure her full cooperation and confidence she must be 
told not only w^hat to do, but how and why it should be done. In 
the matter of infant-feeding, for example, if it is explained to a 
mother of fair intelligence that condensed milk and the proprietary 
foods, when prepared for use, are weak in fat, weak in proteid, and 
contain much less of these nutritive elements than does mother's 
milk — the food which the child has a right to demand — she will at 
once be convinced that such food is not suitable for her baby. It 
will then be comparatively easy to convince her that cow's milk 
for the great majority of infants is the only suitable substitute for 
mother's milk. 

It is my object to have the mother know as much of child life 
as she is capable of understanding. She is encouraged to attend 
lectures to mothers and mothers' meetings. She is advised to 
subscribe for mothers' journals and to buy books and reading-matter 
for mothers, for the reason, which is perhaps not entirely unselfish, 
that I have had signal success with the infants of w^ell-informed 
mothers. The children of such mothers, as the result of a properly 
regulated life, have better appetites and less illness; they are stronger 
and more vigorous than those indifferently cared for. If disease 
attacks them, they make more prompt and satisfactory" recoveries; 
if an operation is required, intelligent mothers appreciate its necessity. 
As children, their offspring are better specimens of the race, and as 
adults, they will always have reason to be thankful that their mothers 
were educated and efficient in child management. 

' A mother should know what to do in case of sudden illness and 
she should know when to send for the doctor. I teach the mothers 

^ Manufactured by The International Sanitary Manufacturing Co., Portches- 
ter, New York. 



22 GENERAIv CONSIDK RATIONS 

of my patients never to look lightly upon a sore throat or trust to 
their own judgment in dealing with it, but promptly to seek medical 
advice, with the result that repeatedly cases of diphtheria have been 
on the way to recovery when an ignorant or careless mother would 
be treating them by home methods with the children growing rapidly 
worse. By the ignorant, I do not necessarily mean the poor. Many 
of my dispensary mothers show surprising intelligence and good 
judgment when they are most needed. 

A mother should be taught never to rely upon her own judgment 
if a child complains of persistent pain in the stomach. She is told 
that it oftentimes means a great deal more than simple colic. I 
have known precious lives to be lost because the mother made a 
diagnosis of colic and treated the child for such a condition, when 
it had appendicitis. A mother should be instructed to stop milk, 
to give a dose of castor oil and a carbohydrate diet with the first 
indication of summer diarrhea, and then to send for the physician, no 
matter how trivial the indisposition. She is told that, in the intes- 
tinal diseases of summer, the child is poisoned by a process of bacterial 
infection in the intestinal contents and that milk furnishes the best 
food for the bacteria that cause the trouble. She is told that the 
child who is badly fed and who has repeated attacks of indigestion 
and diarrhea during the winter and spring will be much more suscep- 
tible during the summer to serious intestinal involvement; and 
that proper feeding and the immediate correction of digestive errors 
are of paramount importance at all seasons of the year. She is told 
how to dress her child in summer. She is taught the necessity of 
fresh air at night and the value of outdoor life at all seasons of the 
year; that a so-called *'cold" is usually an infection of the respiratory 
mucous membrane due to dusty ill-ventilated rooms or dusty streets 
and not to the fact that a window was left open for a few moments ; 
that a child cries from other causes than hunger ; that fever, whatever 
its cause, requires that the child's food be weakened at least one-half 
in the bottle-fed, and that an ounce or two of water be given before 
nursing in the breast-fed; that drug-giving to children is a habit 
which is to be condemned, the child in health requiring little or 
nothing in that line. 

With an educated mother not only are our results much more 
satisfactory, but the annoying outside influence of officious relatives 
and neighbors is thus effectually neutralized. 



THE NURSERY MAID 

In certain stations and conditions of society, the young child is 
cared for by its mother with the assistance of the immediate members 
of the family. In thousands of homes, however, a helper is employed 
to take charge of the child or assist in its care. The selection of a 
nursery maid is a matter of much importance. Schools for training 



THE NURSING-BOTTLE AND NIPPLE 23 

nursery maids exist in New York city, Boston, Albany, Newark 
(New Jersey), and doubtless in some other cities; but, although 
such trained help is greatly to be desired, the supply is very limited. 
Some of my best children's attendants have been women who, 
although they have not passed the meridian of life, still have reached 
the seasoned age when the attractive qualities of policemen and 
grocery boys have faded into a dim recollection ! Any industrious, 
sensible young woman of quiet tastes who is fond of children, can be 
trained in a few weeks into a most useful helper. The association 
of the nursery maid and child is a close one, and it is the physician's 
duty to know that the applicant is physically fit for the position. 

During the past year the writer has known of three nursery 
maids who developed pulmonary tuberculosis while in service. 
Not only should the applicant's lungs be examined, but also the 
mouth, nose, and throat. Carious teeth, and diseased conditions 
of the throat and nose, should receive careful attention before the 
maid is allowed to assume the position. It is also important that 
something of the applicant's previous life should be known. 

One of the most important things to know about an applicant 
in a large city, and one most difficult for the physician to discover, 
is the matter of leukorrhea or vaginal discharge.^ This, however, 
can usually be discovered by the tactful young mother. Not only 
should the ideal nursery maid be physically fit, she must be mentally 
fit as well. For proper mental and physical development, children 
must be entertained and pleasantly employed. An ill-natured, 
impatient nurse should be forced to seek other employment. It 
should not be a task for a child's attendant to play with him. A 
woman should not be condemned, however, because she fails with 
any given child. With a child differently situated, with a different 
temperament, the results may be perfectly satisfactory. I have 
known not a few such instances. 



THE NURSING-BOTTLE AND NIPPLE 

There are two requirements that a nursing- bottle must fulfil: 
It must have a capacity sufficient for one full feeding and it must be 
so constructed as to be readily cleansed. The oval bottle (Fig. i) 
with rounded edges answers best. These may be obtained in sizes 
of from three to nine ounces. As many bottles are needed as there 
are feedings in twenty-four hours. The bottle should be boiled 
once a day, scrubbed with a stiff brush with hot borax water, and 
remain in the borax water until needed. Two teaspoonfuls of borax 
to a pint of water is the strength usually used. Before using, bottles 
should be rinsed in plain boiled water. The straight, black nipple 

^ A very severe gonorrhea was recently contracted by one of my patients 
from a nursery maid. 



24 GENERAL CONSIDERATIONS 

(Fig. i) is also preferred, for the reason that it can be turned inside 
out and easily cleansed. A nipple which cannot be turned should 
never be used. After using, a nipple should be turned and scrubbed 
with a stiff brush and borax water — a tablespoonful of borax to a 
pint of water. When not in use, the nipple should be kept in borax 
water. Before placing it on the bottle, it should be rinsed in boiled 
water. The nipple should be boiled once a day. The blind nipples — 
those without holes — are the best. Holes of the 

^^ required size may be made with a red-hot cam- 

^H brie needle. 

^m THE NURSERY 

^^^^^ The nursery should be the largest and best 

V^HP ventilated room in the house. In a city home it 

/. A is well to have it on the third or fourth floor with 

a southern exposure. In apartments, quiet and 

the possibility of free ventilation and sunlight 

,g must be considered in selecting the room. For 

if -^ - - -I the sake of quiet, the nursery should not com- 

I municate with the sleeping- rooms of older chil- 

* dren. 

!, , In placing children in sleeping-rooms or in a 

nursery or in estimating the capacity of hospital 
wards for children, it is to be remembered that at 
least one thousand cubic feet of air-space should 
be allowed to each child. 

The floor of the nursery should not be car- 

; . ;| peted. A hard- wood floor is best. If this is not 

'i ^ possible, covering the floor with oil-cloth or lino- 

; I leum is always possible. This can be cleaned with 

' a damp cloth every day. A broom should never 

fbe used in a nursery. Paint or hard finish on the 
walls is preferable to paper. There should be at 
least two windows and an open fireplace. If pos- 

^\_, ^'"' . sible, the bath-room should be connected with the 

Fig. I.— nursing-bot- uurscry, to be used not only for bathing the child 

TLE AND Nipple. but as a ''changing room." The child's napkins 

should not be changed in its living-room if it can 

be avoided. It is needless to say that napkins should never be dried 

in the nursery. 

Steam heat as ordinarily used today is the least desirable means 
of heating, on account of its uncertainty. In many New York 
apartments of the better class, the fires are banked at lo p. m. ; the 
temperature when the child retires is from 70° to 80° F. or more; 
by five or six o'clock in the morning a fall to from 50° to 60° F. has 
taken place. Such a change in the temperature, with the tendency 
of children to kick off the bed-clothes, explains many cases of ton- 



BASKETS FOR EARLY EXERCISE 25 

sillitis and bronchitis. The temperature of the nursery should be 
kept as even as possible. When for any reason this cannot be con- 
trolled, it is best to have two means of heating, so that when one fails 
the other may be used. The open-grate fire or a small wood-stove 
is best. Gas ought never to be employed as a means of heating a 
child's sleeping-room, on account of the rapid exhaustion of the 
oxygen which results from its use. 

The furniture of the nurser)^ should be of the plainest. Hard- 
wood chairs and tables with enamel or brass cribs or bedsteads 
should be used. There should be no article of furniture or fur- 
nishings in a nurser}^, that cannot be washed. There should be in 
the bath-room or in some room adjoining, a pail containing some 
disinfectant solution, such as carbolic acid, i : 100, or carbonate of 
soda solution, i ounce to 2 gallons of water, in which the napkins are 
placed as soon as soiled. 

There should be two shades at each window, a light and a dark 
shade, so that it will be possible to darken the room during the 
sleeping time, as well as to exclude the early morning light, which 
is the usual cause of too early waking. Babies should be taught 
to sleep until at least six o'clock in the morning. This is far better 
for the child and also for the mother if she occupies the same room. 
The unnecessary habit of an early waking at four or five o'clock will 
in most instances readily be broken by keeping the room dark. 

The nursery should have suitable means for ventilation. For 
this purpose, aside from the fire-place, I have found the window- 
board (page 44) of no little service. It can be made of any width. 
Ordinarily, I have it made about four inches wide. It is sawed 
so as to fit tightly under the lower sash. This leaves an open space 
corresponding to the width of the board between the upper and 
lower sash, and allows the entrance of a current of air which is directed 
upward. There should be a thermometer in every child's living- 
room or nursery. It should register from 70° to 72° F. bv dav and 
from 65 ° to 68 ° F. by night. The nursery should be given an hour's 
airing twice a day. The child should sleep alone in its crib. It 
should not sleep with an adult or an older child. The old-fashioned 
cradle in which generations have been rocked may be an interesting 
heirloom, but under no circumstances should it be removed from 
its place in the garret. It is realized that the above suggestions are 
not applicable in many homes. Nevertheless, if we aim at the ideal, 
existing conditions, no matter how unpromising, will invariably be 
made better. 

BASKETS FOR EARLY EXERCISES 

It is a mistake made in many families to have the baby in the 

arms a greater part of his w^aking hours. This practice should be 

discouraged by physicians, for when the child is held, there is always 

a tendency to make him sit upright on the arms or knee without 



26 GENERAL CONSIDERATIONS 

proper support. During the early months of Hfe the vertebrae and 
vertebral ligaments are not sufficiently developed to support the 
heavy head and trunk. If this thoughtlessness on the. part of 
parents with its attendant dangers were explained, there would be 
fewer cases of displaced scapulae and spinal curvature to be treated 
later on. Many of the cases of spinal curvature which we see are 
the direct outcome of such early abuse of the spinal column. Still, 
it is not desirable that the child should constantly occupy its crib. 
A large clothes-basket in which a thick blanket and pillow have been 
placed furnishes a safe playground for a small baby. For the first 
few months he will lie on his back and amuse himself in his own 
peculiar way. After the 'sixth month, when he may be allowed to 
sit up for a short time each day, a pillow should be placed behind 
his back for support. The basket furnishes plenty of room for toys 
and other means of entertainment. When the child begins to stand 
and attempts to walk, the basket period is at an end and the exercise 
pen (page 37) should be brought into use. 

THE CARE OF THE STUMP OF THE UMBILICAL CORD 
The space devoted to the care of the umbilical cord might seem 
out of place in a work of this nature. The excuse for it is the fre- 
quent appearance in private practice and in out-patient clinics of 
infants with umbilical polypi, granulomata, suppurating umbilical 
stumps, or an eczema involving a considerable area about a moist, 
actively secreting umbilicus. The management of granuloma, 
polyp, and localized eczema about the umbilicus has been referred 
to elsewhere. In order to secure a rapid and complete cicatrization 
after the cord falls, it is always desirable to keep the parts dry. I 
have used with gratifying success a powder composed as follows : 

I^. Pulveris acidi salicylic grs. x 

Pulveris acidi borici grs. xxv 

Pulveris amyli 

Pulveris zinci oxidi aa 5 ss 

Over this powder, which is used freely in the open wound, is 
placed a pad of gauze to hold it in position. The dressing should 
be changed and fresh powder applied every time the child is fed. 
For the small unhealthy granulations which will often be present, 
cauterizing with a 50 percent nitrate of silver solution may be 
necessary once or twice, after which the powder is used until the 
secretion has entirely ceased and cicatrization is complete. 

CRYING 

It is well for the young infant to cry a little every day. Muscular 
movements involving a greater part of the body accompany the act 
of crying and furnish exercise. Peristalsis is increased, as is often 
evidenced by a movement of the bowels occurring at the time, 
particularly when there is diarrhea. In crying, deep breathing is 
necessary, the lungs are expanded, and the blood oxygenated. The 



SLEEP 27 

well baby cries when frightened, or uncomfortable from hunger, 
soiled napkins, or inflamed buttocks. He cries from pain, from 
heat, from cold, from unsuitable clothing, and during difficult 
evacuation of the bowels. He also cries when displeased or angry. 
Authors are prone to refer to the diagnostic value of an infant's 
cry. It is my belief that characteristic cries are not to be depended 
upon sufficiently to give them a differential diagnostic dignity. 
Children slightly but painfully ill may cry incessantly for an hour 
or two. Thus, with intestinal colic, where the cry is loud and con- 
tinuous until the child is relieved or until he falls asleep from exhaus- 
tion; Earache is not an infrequent cause. The habitual criers, the 
restless and vigorous, crying, whining infants, are uncomfortable. 
With very few exceptions the trouble will be found in the intestinal 
tract. The well-trained, normal child, whose nourishment is suitable, 
is seldom troublesome. When well, all babies are naturally good- 
natured and happy in their own way. Badly managed, spoiled 
infants often cry vigorously when left alone. W^hen attention is 
given them, when they are taken up and talked to, the crying ceases. 
This readily tells us that pain or discomfort was not an element in 
causing the cry. In these infants, discipline, not medication, is needed. 
The management of the habitual crier involves the relief of the con- 
dition which causes the discomfort, or the most rigid disclipine, 
when it is demonstrated that we are dealing wth a " spoiled infant." 

SLEEP 

The infant that sleeps well is almost always a normal, well-fed 
baby. Irritability and sleeplessness are associated with indigestion 
more frequently than with any other disorder. During the first 
few days of life, the sleep, in normal conditions, is almost unbroken, 
except when the infant is fed. During the first month the infant 
sleeps about twenty-two hours out of every twenty-four. During 
the second and third months, from twenty to twenty-two hours. 
At the sixth month the child should sleep from 6 p. m. to 6 a. m. 
without interruption other than for feeding or nursing, which need 
cause very little disturbance. At this age there should be a two-hour 
nap during the morning and a two-hour nap in the afternoon, although 
it is not well to have the baby sleep after three o'clock in the after- 
noon. The twelve-hour night rest should be continued until the 
child is six years of age. The day naps will gradually be shortened 
by the child. At one year of age, one hour in the morning and two 
hours in the afternoon suffice. From the eighteenth month to the 
second year, the morning nap is given up. Afternoon rest for at 
least one and one-half hours should be continued until the child 
is six years of age, and longer if he is inclined to be delicate. Regular 
sleep is largely a matter of habit, and if the infant is started right 
with suitable feedings given at definite times, followed by the proper 
period of sleep, but little trouble will be experienced with sleepless- 



28 GKNKRAL CONSIDE:rATIONS 

ness. When sleep is disturbed and broken, it means bad habits, 
unsuitable food, minor forms of indigestion, or positive illness of 
some kind. Sleep is important for purposes of growth, not only in 
early infancy but throughout childhood. Not a few infants form 
habits of sleeping in the daytime and being wakeful at night. This 
is best remedied by keeping the baby awake, when he should be, during 
the day, by entertainment and by keeping him in a well-lighted 
room. I am sure that the satisfactory results which I have had the 
good fortune to achieve in the treatment of secondary malnutrition 
and anemia have been due in part to my insistence that the child 
sleep in a quiet, darkened room for two hours after the noonday meal. 
The energy expended in twelve hours by an active child is incal- 
culable, and when a portion of this energy is reserved and the body 
fortified by rest and sleep during the middle of the day, it means a 
greatly diminished daily expenditure of strength units. 

KISSING 

Such a topic may be considered out of place in a work of this 
nature, but in taking up the child's management in all its details, 
it is my belief that a few remarks on this subject are perfectly in 
order. Every detail of the child's daily life should be under the 
oversight of the physician, and if he is to do his full duty, he must 
give a certain amount of voluntary, unsought advice. A custom 
concerning which he will not be consulted is the matter of that 
most unhygienic practice of kissing. 

A child should never be kissed on the mouth, and this is a standing 
order with all my patients. I have known, in my own private 
practice, of instances where tuberculosis, diphtheria, and syphilis 
have been communicated from the diseased adult to the innocent 
child by this disgusting practice. Neither should the child's hands 
or fingers be kissed, as the hand or fingers of the majority of 
babies is in their mouth many times an hour. If the baby is 
the first one that has graced the household, and must be kissed, 
this can be accomplished with the least damage, if the kiss is im- 
planted on the head or forehead. The parents must make the rule, 
and they must set the example by adhering to it themselves. Among 
my patients, a nurse who is known to have kissed the child is pun- 
ished by dismissal. Because an adult is apparently well, is no excuse 
for this indulgence. Healthy adults frequently have in their mouths 
the germs of tuberculosis, of diphtheria, and of other diseases, and 
never suffer from their presence because they are strong adults 
with vigorous mucous membranes which do not furnish as favorable 
a soil for the growth and development of pathogenic bacteria as do 
the more delicate mucous membranes of the young. It is criminal, 
therefore, to subject the child to such dangers. Scarlet fever, 
measles, and whooping-cough are all most readily transmitted at 



BATHS 



29 




the beginning of an attack through the close contact required by 
a kiss. 

Kissing should not be allowed among children. Little girls are 
very prone to follow the customs of their mothers, whether good or bad ; 
hence, the necessity of advice in this direction which will be partic- 
ularly impressed upon the physician if he will observ^e the inter- 
change of bacteria which takes place on the sailing 
or arrival of any of our large ocean steamers ! 

BATHS 

The newly born child should be given daily 
a basin-bath with lukewarm, boiled w^ater and 
castile soap until the cord falls and the navel 
heals. AA^hen this has taken place the tub-bath 
may be given. The temperature of the bath for 
the very young infant should not be below 95° F., 
nor above 100° F. Very young children should 
not be kept in the water more than three min- 
utes. After the third or fourth month a temper- 
ature of 90° or 95° F. is best, the child being kept 
in the w^ater about five minutes. At this age I 
prefer to have the tub-bath given at night, just 
before the child is put to bed. A basin-bath may 
be given in the morning. When the child is a 
year old and fairly vigorous, the temperature of 
the water at the beginning of the bath should be 
90° F. This should gradually be reduced to 80° F. 
by the addition of cold w^ater, the child being 
vigorously rubbed with the hand while in the 
water. The temperature of the room should be 
from 76° F. to 80° F. during the bath, and win- 
dows and doors should be closed. When removed 
from the tub the baby should be dried quickly and 
thoroughly, and the folds of the skin should be 
well powdered. A sponge should never be used 
in any portion of the bathing process. It should 
never be included in the nursery outfit. It is 
never clean after it has once been used. Some 
children have a dread of the bath, and cry fran- 
tically when placed in the water. This is due to 
fear, and may usually be overcome by placing a sheet over the tub 
and lowering the child on it into the water. 

The Cold Douche. — For "runabouts " from two to three years old 
it may not be wise to use water below 70° F., but many patients 
over three years have the water applied in the form of a cold douche 
after the cleansing bath, during the entire tw^elve months at the 




Fig. 



2.— Bath Ther- 
mometer. 



30 GENERAL CONSIDKRATIONS 

temperature at which it runs from the faucet. In winter, in New 
York houses, this ranges from 50° to 60° F. 

In giving the cool douche the child should stand in warm water 
covering the ankles. The douche may be used in the form of a 
spray or shower or the water may be applied by means of a sponge 
moistened with it at the desired temperature. The head, if the 
shower or spray is used, should be suitably protected by an oil- 
skin or rubber bathing cap. 

After the cold douche there should be a vigorous friction of the 
skin with a rough towel. If there is not a quick reaction, if the skin 
does not become warm and glowing, warmer water should be used. 
So also with blueness of the extremities and "goose flesh," use 
water less cold, but do not discontinue the douche. 

In the great majority of homes the bathing of the children can 
be carried on with greater convenience immediately before their 
bedtime. The child should receive the warm bath and the cool 
douche, and then, in night-clothes, a warm wrapper, and suitable 
foot covering, he should eat his supper. However, if this time is not 
convenient, he may be given the evening meal at 5.30 or 6.30, followed 
in one hour by the bath and bed. 

Tub-baths for Fever. — Place the child in water at a tempera- 
ture of 95° F. and reduce to 75° F. or 80° F. by the addition of ice 
or cold water. The duration of the bath should not be more than 
ten minutes, constant friction being maintained during the entire 
process. 

Basin Bathing for Fever. — Add eight ounces of alcohol to a 
quart of water at a temperature of 70° F. The child is stripped and 
covered with a flannel blanket, and the entire body sponged with 
this solution for ten or fifteen minutes. Drying the skin should not 
be practiced. Allow the alcohol and water to evaporate from the 
body surface, as by this means a greater reduction in the temperature 
will be effected. 

Either the tub-bath or the basin-bath may be used by the mother 
in case of sudden high fever — 104° to 105° F. — before the physician 
arrives. She should be so instructed. 

Bathing for Comfort in Hot Weather. — The basin-bath and 
tub-bath may also be used as a means of relief during very hot 
weather. One or two basin-baths a day, with a tub-bath at bedtime 
during this trying season, will give the child much relief, and help 
him to pass safely through it. The very young feel the extreme 
heat most acutely, and endure it with difliculty. I know of nothing 
else that will give a restless, uncomfortable, heat-tormented child 
such a refreshing sleep as will a cool tub- or basin-bath. 

Mustard Bath. — A mustard bath is prepared by adding a 
heaping tablespoonful of mustard to 6 gallons of warm water. 
From five to ten minutes in the bath is all that is advisable to allow. 
The special use of the mustard bath is in the treatment of convulsions ; 
it will be found useful also for nervous children who sleep badly* 



WEIGHT 31 

Two or three minutes in the mustard water, followed by a quick 
rubbing immediately before going to bed, are oftentimes all that will 
be required to induce refreshing sleep. 

Brine Bath. — A brine bath — an even tablespoonful of salt to 
each gallon of water at a temperature of 95° F. — is of great service 
with very delicate, poorly nourished children. Its action is that of 
a tonic. If the child is thoroughly soaped and washed with plain 
water, and then immersed in the brine bath, no further tubbing is 
necessary. The child should be kept in the bath for five or ten 
minutes, constant friction being continued during the entire time. 
The brine bath is not applicable to children with intertrigo or eczema, 
or any condition in which there is an inflammation of the skin. 

Soda Bath. — The soda bath is of some serv-ice in cases of prickly 
heat from which many children suffer during the summer. A 
tablespoonful of bicarbonate of soda should be added to each half 
gallon of water used. The temperature of the water should be that 
to which the child is accustomed. From tw^o to four minutes in the 
w^ater suffices. There should be little or no friction of the skin. 
The child should be dried with soft towels. 

Bran Bath. — The bran bath also is of service in prickly heat. 
One cup of bran is mixed with the water in the bath-tub and the 
same method employed as for the soda bath. 

Starch Bath. — The starch bath also is useful in prickly heat. 
One-half cupful of powdered laundry starch is mixed with the water 
in the bath-tub, and the same method employed as for the soda bath. 

Hot Bath. — Place the child for from three to five minutes in 
water which has been raised to a temperature of 105° or 110° F. 
Constant friction of the extremities is maintained while in the water. 

WEIGHT 

The average weight of the full-term new^ly bom infant varies 
from six to nine pounds. Some are born at term weighing less than 
six pounds and a few weighing over nine pounds, but in the great 
majority the birth- weight will be found between these figures. Holt 
found from a study of the records of three large maternity institu- 
tions in New York city as follows : 

The average weight of 568 females w^as 7.16 pounds. 

The average weight of 590 males was 7.55 pounds. 

Every family which can afford it should have a scale (page 33) 
for weighing the baby, for only by regular weighing during infancy 
and childhood can we gain an accurate knowledge of the growth of 
the child. During the first five days of life there is usually a loss in 
weight of from four to six ounces. After this initial loss, which may 
be expected but which does not always occur, a weekly gain in weight 
is to be looked for, the child regaining the birth- weight on the eighth 
or tenth day. At first it is advisable to weigh twice a week, or 
even daily, if the child is not progressing satisfactorily. After the 



32 gkne:raIv considerations 

second month, when he is making satisfactory progress, a weekly 
weighing will answer, and this should be continued until the child 
is one year of age. During the second year, bi-monthly weighings 
are sufficient. Girls of the same age, after the first year, will average 
from one-half to one pound lighter than boys. During the third 
year, monthly weighings will be sufficient to enable one to keep 
in touch with the child's condition. During the first six months 
of life a weekly gain of from four to eight ounces has been made 
by the well children under my care. When a child does not make 
at least an average gain of four ounces weekly, I do not put him in 
the ''doing well" class, but look into his care and nutrition to learn 
what is wrong. Children vary in their growing capacity. Some 
will increase in weight rapidly, gaining three ounces a day, which I 
have seen in some cases, while others will make a slower gain and yet 
be perfectly well. Through the care of many children, I have come 
to regard four ounces as the minimum weekly gain for a well child. 
In a well infant the birth-weight should be doubled by the fifth or 
the sixth month, and in one year his weight should be a little over 
two and one-half times that at birth. During the second year a gain 
of from five and one-half to seven pounds will usually result under 
proper conditions. During the third year from five to six pounds 
will be added. At the fifth year the weight should be in the neighbor- 
hood of forty-one pounds. It is not to be inferred that these are 
arbitrary figures or that perfectly w^ell children may not be under 
or above the figures given at the ages mentioned. They are, however, 
to be regarded as the averages for the different ages. 

A weight chart with its colored ' ' normal ' ' line will not be found 
in this book and physicians are advised against its use. Time and 
again I have seen well infants, though slow in growth, made ill by 
overfeeding, in the vain attempts of an ambitious mother or nurse 
to keep her infant up to the " normal " line. It may be said that the 
weekly weighing might have similar effect; not so. Here there is 
nothing for comparison — no normal red line staring the mother in 
the face. 

The weighing alone is not sufficient to tell us absolutely as to 
the development of children. I have seen condensed-milk babies who 
showed a most satisfactory weight curve, yet who, on examination, 
were by no means up to the requirements for their age as regards 
their bone and muscle development. A nursing or bottle baby 
should be examined once a month in order to determine if the prog- 
ress is along the desired lines as shown by the condition of the 
teeth, the fontanel, the long bones, and the muscles. 

The following table from Holt's " Diseases of Infancy and Child- 
hood" gives the weight and height of children from birth to the 
sixteenth year. The weights under five years are in children without 
clothing. After the fifth year the weight of the clothing is to be 
deducted. The average weight of house-clothing, according to 



WEIGHT 33 

Holt, who quotes Bowditch, is at the fifth year 2.8 pounds for both 
sexes; at the seventh year, 3.5 pounds for both sexes; at the tenth 
year, 5.7 pounds for boys and 4.5 pounds for girls; at the thirteenth 
year, 7.4 pounds for boys and 5.6 pounds for girls; at the sixteenth 
year, 9.7 pounds for boys and 8.1 for girls. These weights must 
be deducted from the gross weights in order to obtain the net weights 
of the children. The season of the year, of course, would make some 
difference as to the weight of the clothing, although this point is 
not mentioned by the observers. 

Age. Sex. Weight. Height. 

Pounds. Inches. 

TJirth /Boys 7.55 20.6 

^^^ \ Girls 7.16 20.5 

. ^, /Boys 16.0 25.4 

6^°^^^^ \Girls 15.5 25.0 

-^ ^, /Boys 20.5 29.0 

12 nionths I (. .4 J 9 3 28.7 

,0 ^1, /Boys 22.8 30.0 

18 months 1^-4 22.0 29.7 

2 vears ^ ^°>^^ ^6.5 32.5 

"^ y^^^^ \ Girls 25.5 32.5 

^ y^^^""^ \ Girls 30.0 35.0 

^ ^^^^^ \ Girls 34.0 38.0 

^ y^^^^ \ Girls 39.8 41.4 

. / Boys 45.1 44.1 

^^^^'^ IGirls 43.8 43.6 

' ^^^^^ • ■ \ Girls 48.0 45.9 

^ ^^^^^ 1 Girls 52.9 48.0 

^ ^^^^^ \ Girls 57.5 49.6 

1" y^^^^ 1 Girls 64.1 51.8 

11 vears ^ ^^^^ ^^.4 54.0 

^^ y^^^^ 1 Girls 70.3 53.8 

,^ /Boys 79.8 55.8 

^^ y^^^^^ \ Girls 91.2 58.7 

^* y^^^^ \ Girls 100.3 60.3 

^^ >^^^^^ \ Girls 108.4 61.4 

16 vears ^ ^^^^ ^^3.7 65.6 

^^ >^^^^^ \ Girls 113.0 61.7 

Scales. — A scale for weighing the baby is a very necessary 
adjunct to the nursery furnishings. There are several varieties of 
scales on the market known as "baby scales." Their usual construc- 
tion is that of a basket for holding the baby, the basket being supported 
by a steel rod which rests upon a spring. A needle indicates on a 
dial the weight of the child. This variety of scale is very unsatis- 
factory : it gets out of order easily, it is expensive, and with a vigorous, 
3 



34 GENERAI. CONSIDERATIONS 

kicking child, the rapid oscillation of the needle makes an accurate 
reading of the weight a difficult if not an impossible matter. Further, 
the weight capacity of these scales is but twenty pounds. When 
the child's weight reaches this figure, it necessitates the purchase 
of another scale. The scoop and platform scale used by grocers 
(Fig. 3) answer the purpose far better than any other. They do not 
easily get out of order, they weigh correctly from one-half ounce to two 
hundred and eighty pounds, and being very simple in construction 
they can readily be understood. The infant rests on his back in the 



Fig. 3.— Scoop and Platform Scale. 

scoop during the weighing process ; older children stand on the plat- 
form. These scales are inexpensive, costing but $3.75/ 

HEIGHT 

The length or height of children at the various ages is for con- 
venience included in the above table. From the standpoint of 
health or development, this is of no great significance. The length 
at birth usually varies from 19^ to 21 inches. Children suffering 
from tardy malnutrition, particularly if syphilitic, may be under- 
sized. Not a few of the non-specific malnutrition and anemic children 
are tall and thin. It is often a matter of no little distress to parents, 
that their children are undersized. Short mothers and fathers 
cannot expect very tall children. They will probably be larger than 
the parents if they get the right care, but they cannot be expected 

^The scoop and platform scale may be obtained at the Metropolitan Hard- 
ware Co.'s, Church and Vesey Streets, New York. 



THE TEETH 35 

to grow as much as some of their playmates, whose fathers and 
mothers are tall. The height bears much less relation to the con- 
dition of the child than does the weight. 

THE TEETH 

Twenty teeth comprise the first set. In the well child the first 
tooth usually appears between the sixth and the eighth months; 
the first teeth may, however, in perfectly normal cases, come earlier 
or much later. I have known well, vigorous children who did not 
get a tooth until the thirteenth month. The first teeth are usually 
the two lower central incisors. The four upper incisors and the 
two lower lateral incisors appear normally between the eighth and 
the tenth months. The first four molars appear between the twelfth 
and the fifteenth months. The four canines between the eighteenth 
and the twenty-fourth months, the four posterior molars, which 
complete the first set, between the twenty-fourth and the thirtieth 
months. This regularity in the appearance of the teeth is by no 
means constant, even in well children. I have repeatedly seen the 
upper central incisors cut first and in several instances the upper 
lateral incisors have appeared first. In delayed dentition in rachitis 
and other forms of malnutrition, the teeth are very apt to appear 
irregularly. In a markedly rachitic dispensary patient the bicuspids 
were the first teeth cut. 

Care of the Teeth. — As soon as the teeth appear they require 
attention. Until the second year is reached the mouth should be 
washed out at least twice a day with a solution of boric acid — one 
ounce to a pint of water. This can best be done by means of absor- 
bent cotton wound around the tip of a clean index-finger and after- 
ward dipped into the solution, when it should be applied with 
gentle friction to the gums and teeth. When a child is two years 
old, it is well to begin the use of a soft tooth-brush and a simple 
tooth-powder composed of the following ingredients: 

I^. Precipitated chalk § j 

Bicarbonate of soda . 5 j 

Oil of wintergreen q. s. 

The child should also be instructed as to the proper use of a 
quill toothpick. The teeth of every child over two 3^ears of age 
should be examined by a dentist every six months. If cavities are 
discovered in the first teeth they should be filled with a soft filling. 

The milk teeth are lost between the sixth and the eighth years. 
They should not decay, but fall out or be forced out by the second set. 

The Permanent Teeth. — The permanent set comprises thirty- 
two teeth. The second dentition begins about the sixth year, and 
is usually completed about the twentieth year, although it may be 
delayed several years. The permanent teeth appear in somewhat 
the following order: 



36 GENKRAL CONSIDERATIONS 

First molars sixth year. 

Central incisors sixth to seventh year. 

Lateral incisors seventh to eighth year. 

First bicuspids ninth to tenth year. 

Second bicuspids ninth to tenth year. 

Canines eleventh to twelfth year. 

Second molars thirteenth to fifteenth year. 

Third molars after the eighteenth year. 

Dentition. — It is claimed that the eruption of the teeth is a 
physiologic process and as such is not productive of harm. In 
normal well babies this is generally the case. There may be a 
shght fever and restlessness with loss of appetite, associated with the 
eruption of a tooth, but the disorder is usually very temporary in 
character. With delicate children, particularly in those who teethe 
late, as in the rachitic when several teeth are cut at one time, not 
a Httle inconvenience may be caused by dentition. Even these 
patients, however, rarely have grave digestive disorders. In a large 
experience with teething infants, I have known but three in whom 
convulsions were apparently directly dependent upon dentition. 
One of these was a rachitic institution child, who cut his first tooth at 
the ninth month, and with each of the three succeeding teeth, which 
were cut during the next three months, there were convulsions 
without any other signs of illness. 

Temporary digestive disorders are of very frequent occurrence 
in this type of child, during an active dentition. The child may 
be restless and irritable and perhaps there is fever of a degree or 
two. His digestive capacity is lessened, but the usual diet is never- 
theless continued. Fermentative diarrhea results, which may be, 
and often is, the starting-point of grave intestinal disease. When 
it is apparent that the child's generally good-natured daily habit of 
life is being unfavorably influenced by dentition, the food should 
temporarily be reduced, particularly if the weather is hot. 

Breast babies may be given water before each nursing so as to 
reduce the capacity for milk. In the bottle-fed two or three ounces 
of the food mixture may be removed from each bottle, replacing 
the amount with boiled water. 

That cough, respiratory and skin diseases are immediate results 
of dentition is without foundation. During active dentition when 
the gums are distended and swollen from pressure, relief will often 
be furnished promptly by rubbing through the prominent points 
of the tooth with a clean towel over the index-finger. Lancing 
alone may be performed, but unless the tooth is well advanced it 
is quite possible that the gums will reunite over the tooth, forming a 
cicatrix which will make the eruption more difficult than before. 
If a week or ten days' discomfort can be obviated by assisting a 
tooth through the gum, I fail to see any contraindication to such a 
procedure. 



THE EXERCISE PEN 37 

DAYS TO GO OUT OF DOORS; INDOOR AIRING 

Physicians are frequently consulted as to the age when, and the 
conditions under which, it is permissible to take the baby out of 
doors. To answer this, the place in which the child lives, the season 
of the year, and the age and condition of the patient must be taken 
into consideration. 

A child, regardless of its age, should never be taken out in inclem- 
ent weather. If under one year, he should not go out if the tempera- 
ture is below 20° F. During the midday heat of summer the baby 
is better off in the largest and coolest room in the house, or on a 
shady veranda. On very windy days the young infant should not 
go out, nor when the snow is melting in large quantities, but, although 
unable to go out on account of unfavorable conditions of the weather, 
there should be no lack of fresh air, and in such conditions children 
should be given an indoor airing. For this purpose the child is 
dressed as for the daily outing. All the windows of the nursery or 
some other large room are opened, on one side of the room only. 
The doors should be closed, so that currents of air are avoided. The 
child is placed in his carriage, suitably covered, and wheeled about 
the room for an hour or two. This, if done twice daily, answers 
almost as well as the actual outing. 

This method will be found very useful in ''winter babies" — 
those bom during the late fall or winter months. The indoor airing 
may be given for a week or more, before he is taken out. By this 
means the child is gradually accustomed to a change of tempera- 
ture from that of the average living-room to that out of doors, and 
will not be harmed when he is finally taken out. After an illness 
also, it will afford an earlier means of returning to the daily outing. 
This method of giving a child fresh air will be found useful with very 
delicate children also, who, by reason of their condition, may be 
unable to go out during the winter months, for several weeks at a 
time. There are, however, but few days during the winter that are 
too cold or too stormy for the indoor airing. 

THE EXERaSE PEN 
In another chapter, in speaking of ''colds" and how children are 
exposed to the influences which might bring about what is known 
as a "cold," the custom of allowing a child to sit on the floor and 
play, at all seasons of the year, is referred to as a most frequent means 
of exposure. There is always a current of air near the floor, as one 
readily discovers by resting his hand on the floor, on a cold winter 
day; further, the floor of the average house is naturally the most 
unclean part of the dwelling. Here dust gathers and dirt from the 
street collects as it is brought in on the feet of older members of the 
family. On this necessarily unclean floor, the young child is per- 
mitted to spend a considerable portion of his waking hours. It can 



38 



GENERAL CONSIDERATIONS 



readily be seen that countless numbers of bacteria may be trans- 
ferred through the medium of the hands from the floor to the child's 
mouth. Rugs and pillows, which are sometimes used, while cleaner 
than the floor, are of little assistance in preventing drafts. 

Exercise is very necessary for the child's proper growth and 
development. He must have an opportunity and place in which to 
creep, walk, and run. In order that he may have these advantages 
and not be subjected to unfavorable influences, I have found the 
exercise pen (Fig. 4) of the greatest service. After being bathed, 
dressed, and fed, the child is placed in the pen, on a rug or quilt. 
Toys are given him and the door is closed. He cannot come in con- 
tact with the stove, he cannot roll downstairs, and he is in no danger 
from the rough play of older children. He is given an opportunity 
for active exercise without a possible chance of injury. 

The pen can be made of any size, but the usual size is four feet 
square. It can be made of any light-weight wood, pine generally 
being used. The legs of the pen should be at least twelve inches 




Fig. 4.— The Exercise Pen. 



long, bringing it well off the floor. The pen is so constructed that 
it may readily be taken apart and put together again, iron tenon 
hooks and iron mortices being used to hold the parts together. The 
floor may be made of any thin material. One-half inch pine boards 
nailed together, or papier-mache supported by narrow strips of 
board, may be used. The floor is supported by strips of board about 
one-half by two inches, which are fastened to the inner side of the 



WRITTEN DIRECTIONS 39 

end-pieces. The pen is best placed in the corner of the nursery or 
the hving-room. Its size may be determined entirely by the size 
of the room. During warm weather in the country, it may often 
be used out of doors. 

THE FIRST EXAMINATION OF A PATIENT 

Upon being called for the first time to see a patient, it is my 
custom in every case to take a history. On page 40 is a copy of the 
history record which I use. Form A represents the front of the slip. 
Form B represents the back of the same slip. Further records are 
kept on plain ruled sheets of the same size — 5 X 8 inches. 

When the history is completed the leaves are placed in a Moore's 
loose-leaf binder. 

The patient's family history is carefully taken. The habit of 
obtaining a complete and accurate record as regards family peculiari- 
ties in relation to disease is often of much service, subsequently, if 
not at the time. Upon systematic questioning only will necessary 
facts be brought out relating to tuberculosis, rheumatism, syphilis, 
etc. The child's personal history includes the birth-weight, the 
rate of growth, the nature of previous illnesses, present weight, the 
condition of the skin, eyes, nose, heart, lungs, tongue, bowels, and 
the temperature. All these points are noted and recorded. It is 
only by such an examination, requiring much time and patience, 
that we are able to become thoroughly acquainted with the case in 
hand. 

The child must be stripped for the examination when the condi- 
tions found are entered in the proper spaces in the history chart. 
After the family history has been taken and the general physical 
examination completed, we are in a position to devote ourselves to 
the present condition of the patient. After one has practised for a 
time, thoroughly examining every new case, he is not only impressed 
with its value as bearing upon the management of the condition in 
question, but is also impressed with the unexpected pathologic 
findings in other organs, particularly the heart, throat, and lungs. 
The habit of limiting the examination to feeling the pulse, which 
the doctor usually does not feel on account of the struggling child, 
and the examination of the tongue, which is usually alike unsuccessful, 
merits the severest condemnation. 

WRITTEN DIRECTIONS 

If possible, directions for the care of sick children should be 
given outside the sick-room, so that the physician may have the un- 
divided attention of the mother or nurse. These directions should 
first be given orally and thoroughly explained, and then written 
out in detail. With the child crying, and two or three onlookers 



40 



GENERAI. CONSIDKRATIONS 



HISTORY RKCORD 



FORM A 



child, born at 
Talked at mo 



Date Address 

Mr 
Family History Children living 

Rheumatism 

Nervous Dis. 
Personal History 

Sat up at mo 

General Health and Habits 

Appetite Eats between meals? 

Bowels Bath. 

Sleeps from to ; and from 

Previous Diseases Meas. 

Mumps. 
Gastro-enteric 
Respiratory 
Ear 
Diet from Birth Nursed 
Present History 



Name 

Age 
Ch. dead Cause 

Tuberculosis Syphilis 

Alcohol, tea, etc. Miscarriages 

Labor Wt. at B. 
Teeth at mo. Walked at 



lb. 
mo. 



Wh. Cg. 
Sm-Pox. 



Throat 



to 
C-Pox 



Tea, beer, etc? 

Fresh air 

Snores? 



Scarlat. 



Colds 



Mouth Br.? 
Diphth. 







FORM B 






EXAMINATION 




Weight lb. 


Height 


in. Circ. Head 


in. Circ. Chest in, 


General Condition 


Color 


Muscles Reflexes 


Mentality 




Sits? Walks? 


Talks? 


Head Fontanel 




Sutures 


Cranio-tabes 


Eyes 




Nose Disch. 


Breathing 


Mouth Tongue 




Muc. Memb. 


Teeth 


Throat 




Tonsils 


Adenoids 


Lymph Nodes 




Ears 


Epitrochlears 


Thorax Shape 




Rosary 


Groove 


Heart 








Lungs 








Abdomen 




Umbilicus 


Liver Spleen 


Genitals 




Skin 




Extremities Epiphyses 


Contour 


Feet 


T. °.P. R 


Blood 


R.B.C. 


.Hb. %. W.B.C. 


Urine React. 


S. G. 


Alb. S. Ind 


Mic. Exam. 



WRITTEN DIRECTIONS 



41 



talking, the mother or nurse becomes confused and is almost sure 
to misunderstand or forget important directions. 

If there is not a trained nurse in charge the doctor should show 
the mother or nursery' maid how to perform the various offices for 
the child. She can in a few moments be taught how to read the 
clinical thermometer, how to give a sponge-bath and an enema, and 
how to do many other things which the changed condition of the 
child requires. The use of a croup kettle, which may be needed for 
croup or bronchitis, should always be explained. 

I have found the printed form as given below vers- useful not 
only in making the directions absolutely plain and unmistakable, 
but also as a great time-saving measure. The expense of printing 
is but a trifle. Form A represents the front of the slip. A few minutes 
is all that is necessary' to fill in the blank spaces. Form B represents 
the back of the slip; on this the results of the preceding twelve or 
twenty-four hours are entered. One chart may be made to answer 
for twelve or twenty-four hours, and when the case is finished we 
have a complete record, secured with the expenditure of little time 
and labor. 

FORM A. 



Date 



Name 



Ao^e 



Disease 



ORDERS. 



J. \JKJKX. 

Temperature to be taken even.-. 


..hrs. 


I^ 1 everV. 


. .hrs. 


I^ 2 evers'. 


, ..hrs. 


I^ 3 every. 


...hrs. 


AVhisky every- . 


..hrs. 


Brandy every-. 


..hrs. 


Steam' Inhalations every . 


, ..hrs. 


using 




Sponge Bath for. . .min. every. 


. .hrs. 


at. . .°F., if Temp, reaches 


, ..=F. 


Cool Pack to be given if Temp, reaches 


. . .°F., and continued until 


Temp. 


falls to . . . °F., using ^vate^ at . 


...°F. 



Spray Gargle Throat with 

every , 
Irrigate Throat with 

every , 
Irrigate Ear with 

at . .°F., every, 
Irrigate Colon with 

at . .°F., every. 
Counter-irritation with 
Mustard. . . .parts 
Flour .... parts 
to every, 

Give Enema of Soapsuds 

Saline at . .°F. 

at . . . o'clock if necessary. 



.hrs. 
.hrs. 
.hrs. 
.hrs. 

.hrs. 



Date 



Temperature °F. 

Pulse 

Respiration 

Sleep 

Skin 

Tongue 

Throat 

Lungs 

Heart 
Abdomen 

Xerv-ous Symptoms 
Special Symptoms 



FORM B. 
CLINICAL NOTES. 
^F. °F. °F, °F. 



hour. 



Nourishment 



Vomiting 

Stools no. in 24 hr, 
character 

L'rine amt. oz. in 24 hrs. 
Blood 



42 GENERAL CONSIDERATIONS 

TREATMENT OF THE INDIVIDUAL 

In these days of specialization, in associating with medical men 
in consultation or otherwise, one is sometimes impressed with the 
fact that there is a tendency for the patient, the individual, to be 
lost sight of, to be overshadowed by the immediate disease or con- 
dition from which he may be suffering. In children the success of 
the treatment in practically every chronic ailment depends upon the 
vitality of the individual patient and his powers of resistance as 
a whole, to a much greater degree than is the case with the adult. 
The object of taking up this subject is not to be unkindly critical, 
but to call attention to one phase of the management of children 
which is not sufficiently appreciated by many who have to deal with 
them in their professional work. It is not at all infrequent to 
see poorly conditioned children who have been treated for months 
by local measures for a skin affection, recover without any local 
treatment whatever, other than an attempt perhaps to relieve the 
itching, when their lives are ordered according to the requirements 
of the growing child, as regards nutrition, bowel evacuation, sleep, 
suitable clothing, fresh air, and rational exercise. I have seen cases 
of chronic rhinitis and bronchitis which had persisted for weeks 
respond promptly when local measures, sprays and douches, and 
the internal use of drugs were suspended and the child's life directed 
along rational lines. Those who treat tuberculous and other chronic 
bone diseases, chronic otitis, chorea, and hysteria, are to be reminded 
that their work is not half finished when they have completed the 
usual daily or weekly routine treatment. In these chronic ailments 
it is folly to expect — what a cure really means — a constructive 
process on a destructive diet and improper habits of life. Children 
possess marked recuperative powers, and the rapidity of progress 
toward recovery is often most gratifying when right conditions are 
instituted, as relates to those fundamentals in child management; 
viz., food, sleep, clothing, and bathing. It is the height of folly to 
give children iron for anemia and allow them every form of indis- 
cretion in diet. It should always be remembered that the best results 
are obtained in the treatment of a child, whatever the nature of his 
illness, when he has a child's normal existence, and it is only under 
such conditions that satisfactory results of treatment can be expected. 

NECESSITY OF METHOD IN THE MANAGEMENT OF CHILDREN 
Among the observations that have been made during my work 
in pediatrics among all types and classes of people I have been 
particularly impressed with the fact that some children are the 
source of an immense amount of trouble, while others of no better 
health or greater strength cause very little anxiety on the part of 
their parents. Children differ greatly as regards individual traits 



THE SICK-ROOM 43 

and disposition, but these can be fashioned to a great extent by 
proper management. The more spirited the child, the greater need 
of method in its care. I know mothers who are worn-out, nervous 
wrecks for no other reason than a lack of system in the management 
of the daily life of their children. Thorough-going conscientious 
mothers they may be, but they represent that large number of 
mothers who have never been taught that certain functions and 
duties should be performed only at certain definite times every day. 
This subject is considered not from any moral standpoint but simply 
because of its bearing upon health. 

Beginning with the baby at birth, he should be fed or nursed at 
definite times and at no others. Sleeping should never interfere 
with the nursing hours. The child should have its time for undis- 
turbed repose and a midday nap should be insisted upon at a certain 
hour until the child is six years old. The definite time for meals, with 
properly selected food, should be continued throughout adolescence. 
The child should be bathed at a certain hour and aired at a certain 
hour. "Runabouts" should have their hours for play and should 
retire at a definite time every evening. Such a regime is conducive 
to perfect health, consequently to better growth and development 
and to a stronger manhood. It is idle to say that many parents, 
particularly among the poor, cannot conform to such requirements. 
The poor are just as anxious to do the best for their children as are 
the rich, and will do it to the best of their ability if the reasons for 
doing it are explained to them. If they cannot reach the ideal, 
they will attain to a higher degree of efficiency by striving for it. 
The trouble ordinarily is not with the mother, it rests more with 
the medical adviser, who is largely responsible for the ignorance of 
the mother and the resulting harm to her offspring. 

THE SICK-ROOM 

If there is a choice of rooms for the patient, as there is in many 
households, its size and means of ventilation are important points 
to be considered in its selection. During cold weather a room with 
southern exposure, to which the sun has free access, should be chosen. 
During the hot months of summer, however, the cooler the room, the 
b)etter, provided the size and ventilation are satisfactory. The 
furnishings of the room should be of the simplest, only those articles 
of furniture being allowed to remain which are required for the 
patient. So many of the ailments of childhood are of an infectious 
nature that only articles of furniture should be used that can be 
washed. Curtains, hangings, and plush furniture have no place in 
a sick-room. A plain wood floor is much better than a carpeted 
one. Enameled beds, plain wood or enameled chairs and tables 
are best. A painted wall is much better than a papered one. A 
iireplace is desirable not only for heating purposes but also for 



44 GKNKRAL CONSIDERATIONS 

ventilation. The successful treatment of severe illnesses in children 
is often determined by the careful attention to every detail in the 
care of the patient. A child ill in a dirty, badly ventilated over- 
furnished, overheated room is from the first at a decided disadvan- 
tage. 

The Window-board. — A convenient and simple means for ven- 
tilating the living-room, sleeping-room, or sick-room of a child 
is by what is known as the window-board. A plain inch board is 
sawed the width of the window-frame and placed under the raised 
window in the lateral frame groove resting upon the sill. This raises 
the top of the lower sash above the bottom of the upper one, leaving 
a space between, through which the air enters with the current 
directed upward. The board may be of any width — four, six, or 
eight inches. A width of six inches is commonly used. There are 
various ventilating devices in the market. Those that are of value 
are expensive, and their effectiveness over the simple means above 
suggested does not warrant the expenditure. 



THE NEW-BORN 

PREMATURE AND CONGENITALLY WEAK INFANTS 
There are comparatively few infants born before the completion 
of the twenty-eighth week of pregnancy that survive the first year. 
Reported cases of survival of those born before that time are usually 
unreliable, as they seldom take the child beyond the third month. 
The prognosis is influenced by the factors causing the premature 
birth. If syphilis is present, the child may survive but a day or two. 
Children whose births are forced because of kidney disease in the 
mother do not appear to do as well as others. I have treated a 
large number of premature infants in children's institutions and 
have had anything but brilliant results with them. They not 
infrequently live to be two, three, or four months of age or older, 
but on account of their reduced vitality they readily succumb to the 
slightest ailment, a mild bronchitis or fermentative diarrhea being 
sufficient to terminate their existence. 

In the management of the premature and delicate newly born 
there are three points to be considered — the air the child gets to 
breathe, the nourishment, and the maintenance of bodily heat. It is 
also to be remembered that we are dealing with an undeveloped 
body which is not ready for the environment in which it is placed. 
The premature baby should be handled only when necessary, and 
then in the gentlest manner. Bathing is often best omitted for 
the first few weeks, oil being used for cleansing purposes. Because 
of the undeveloped parenchyma of the lungs unusually good fresh 
air is required. Because of the undeveloped heat-centers the body- 
heat of these infants is quickly lost and must be maintained by 
artificial means. The stomach is small and the digestive processes 
are undeveloped and weak, so that the nourishment should be of the 
most easily assimilable character. 

The maintenance of heat is of the utmost importance. For 
this purpose incubators and their various modifications have been 
used from time to time. My experience with incubators has been 
unsatisfactory. They may by careful watching maintain an even 
temperature, but all that I have used have been defective in supply- 
ing fresh air to the child. My incubator babies invariably have 
done badly. If the electro therm (Fig. 5) is not at hand, the 
padded crib with the child wrapped in cotton and surrounded by 
hot-water bottles is the best means of maintaining the temperature. 
A thermometer should rest between the cotton and the bed-clothing 
as a guide to the nurses in the use of the hot- water bottles. Ordi- 

45 



46 



THB NEW- BORN 



narily this should register from 85° and 95° F., depending upon the 
temperature of the child, whose rectal temperature should at first 
be taken frequently. If there is a tendency for his temperature to 
be greatly reduced — below 95° F. — more external heat will be neces- 
sary than if the temperature were 97° or 98° F. The best device 
among those which I have had an opportunity to observe for main- 
taining artificial heat is the electrotherm advocated and described 
by Holt, ''Diseases of Infancy and Childhood," 1906. 

''These small heaters are attached to an electric fixture, like a 
drop-light. A convenient size is from ten to fifteen inches. It is 
placed between two or three thicknesses of blankets, upon which the 
infant lies in its basket or crib. The degree of heat can be regulated 
according to the amount of electricity turned on. This mode of 
handling premature infants has been given thorough trial at the 




Fig. 5.— Electrotherm. 



Babies' Hospital and has been found to fulfil the indications, with 
children as small as three pounds and as young as seven months, quite 
as well as the incubator, while at the same time being free from its 
dangers. It has not been necessary to raise the general tempera- 
ture of the room. These patients when kept in the wards at an 
ordinary temperature have maintained an even bodily temperature 
much more uniformly than with any other method I have seen, the 
incubator included." 

A mistake often made in the management of premature and 
delicate infants is that of providing too warm air for respiration, 
a glaring defect in most incubators. The best means of decreasing 
a delicate child's vitality and resistance and increasing his chances 
of pulmonary infection, is to supply him constantly with air at 
80° to 90° F. In a modern house the maintenance of this temperature 
usually means an absence of change of air and an abundance of 



PREMATURA AND CONGENITALLY WEAK INFANTS 



47 



bacteria: The patients do best when the temperature of the air 
they breathe is from 70° to 72° F. 

Breast-milk for premature infants born under twenty-eight 
weeks is almost a necessity, and should always be procured when 
possible for all premature children. The mother, with the rarest 
exception, is unable to supply it, so that a wet-nurse should be 
secured. In selecting a wet-nurse for a premature baby it is advis- 
able to take the wet-nurse's baby also, as the premature infant may 
not be able to nurse, or if he nurses he will not take all the milk. 
Pumping the breasts of a wet-nurse will almost invariably dry them 
up, if her own baby is not with her to furnish the 
necessary stimulation of nursing. Sufficient milk ^":-"~. -^ 

may be removed by the breast-pump to supply 
the premature infant if he is unable to nurse, and 
the wet-nurse's baby will empty the breast. For 
premature babies who refuse the breast or are un- 
able to take a nipple, the Breck feeder (Fig. 6) 
may be used as a means of giving nourishment, 
or gavage (page 141) may be brought into use. 
This I have been obliged to resort to in several 
cases. The Breck feeder consists of a graduated 
glass tube, narrowed at one end. Over this end 
is placed a small rubber nipple, the other end being 
closed by a flexible rubber cap. Drawing on the 
nipple is aided and encouraged by pressure on the 
air-filled cap. If the breast-milk proves too strong 
it may be diluted with equal parts of a 6 percent 
sugar solution, from one-half to one ounce of the 
mixture being given at first at inter^^als of from 
one to one and one-half hours. Fourteen to fif- 
teen feedings may be given in the twenty-four 
hours, the amount depending upon the child's di- 
gestive ability. If human milk is not obtainable, 
whey made from whole milk may be given, the 
nutritional equivalent of which is approximately 
I percent fat, i percent proteid, 5.5 percent 
sugar, or one ounce of gravity cream may be given with one ounce of 
milk-sugar and fifteen ounces of water, which gives a nutritional 
equivalent of i percent fat, 5 percent sugar, and .3 percent proteid. 
Canned condensed milk, one part, to 24 to 30 parts of water, 
may be used with advantage as a temporary feeding measure when 
nothing better is available. The food strength is increased, the 
intervals made longer, and the feedings larger, as the patient proves 
able to assimilate the food. 

The premature child requires unusual advantages, and even when 
but one month premature, rarely ''catches up" during the first year, 
sometimes not for two or three years. 





Fig. 



6.— The Breck 
Feeder. 



48 THE NEW-BORN 



ASPHYXIA IN THE NEWLY BORN 

The first step in the management of asphyxia in the newly born 
baby is to clean the mouth and throat of the mucus which will 
almost invariably be found there. This is best done by using as 
a swab the index-finger wrapped with dry absorbent cotton or sterile 
gauze. Spanking the child or the alternate use of a hot (iio° F.) 
and cold (60° F.) bath, the child being rapidly transferred from one 
to the other, will often stimulate respiration by inducing the child 
to cry. When these methods fail, inflation of the lungs by the 
mouth-to-mouth method may be attempted. Various other methods 
of inducing respiration have been advocated from time to time. 
The most effective are those of Laborde, Dew, and Schultze. The 
Laborde method consists in making rhythmic traction on the tongue, 
from twelve to fourteen times a minute, which it is claimed excites 
respiration. The Dew method consists in grasping the infant by 
the back of the neck with one hand and by the knees with the other. 
The upper and lower portions of the child are then approximated 
by a flexion of the thorax on the abdomen ; the reverse movement — 
extension — should also be used, and thus alternate flexion and 
extension are practised fifteen to twenty times a minute. Schultze 's 
method is described by him and quoted by Edgar as follows : ' ' The 
child lying upon its back is grasped by the shoulders, the open hand 
having been slipped beneath the head. The last three fingers 
remain extended in contact with the back while each index-finger 
is inserted into an axilla, the thumbs lying upon and in front of the 
shoulders. When the child thus held is allowed to hang suspended, 
its entire v/eight rests upon the two fingers in the arm-pits. It is 
now swung forward and upward, the operator's hands going to the 
height of his own head; the pelvic end of the child rises above its 
head and falls slowly toward the operator by its own weight, flexion 
occurring in the lumbar region. The thumbs in front of the shoulders 
compress the chest while the hyperflexed lumbar vertebrae and 
pelvis compress the abdomen and through it the thorax; finally, 
the last three fingers on each side compress the thorax laterally. 
As a result of this manoeuver, when properly done, aspirated secre- 
tions flow abundantly from the mouth. The distended heart also 
feels the compression which forces the blood into the arteries. The 
child is now swung back into its original position and supported 
entirely by the fingers in the axillae. The compression of the thumbs 
and last three fingers is removed. The downward swing elevates 
the sternum and ribs, while gravitation and the traction of the 
intestines depress the diaphragm. It is often possible to hear the 
air rush into the infant's glottis as it reaches the original position, 
although this can occur in a cadaver. The amplification of the 
thorax lowers the intracardiac pressure. The child should be 



SEPSIS IN THE NEWLY BORN 49 

swung up and down ten times for the space of a minute. The 
effects of the manoeuver should be as follows: The heart-beat 
increases in frequency, the cadaveric pallor of the skin becomes 
replaced by a rosy hue, and the muscular tonus appears. The child 
is then placed in a warm bath and watched. If the inspirations are 
superficial, a momentary dip in cold water is indicated. If the 
heart-action becomes poor the child should be swung again. If 
prolonged swinging becomes necessary, the root of the tongue should 
be compressed forward in order to raise the epiglottis and permit 
the removal of secretions with the fingers. In premature children 
the thoracic walls are often too soft to benefit by the compression 
of the fingers. In these cases insufflation of air should be practised." 
It is not well to rely upon one method. If necessary, different 
means of inducing respiration may be attempted in a given case. 
The introduction of a catheter or instruments into the larynx has 
not met with favor from obstetricians. 

SEPSIS IN THE NEWLY BORN 

The newly born infant is peculiarly susceptible to infections, 
particularly with the pyogenic bacteria. The avenues for the 
entrance of bacteria into the body are many, and the resistance at 
this period of life is very slight. Infection may be either through the 
mouth, which is probably the most frequent portal of entry, or 
through the nose, the skin, the rectum, the conjunctivae, the urethra, 
the umbilicus, and, in girls, the vagina. Almost any portion of the 
body may be the seat of the infection. It is rare, according to the 
cases upon which I have made autopsies, to find only one organ or 
structure affected. Usually two or three or more portions of the 
body are involved in the septic process. 

The management resolves itself into relieving the system of the 
infection, as is possible when its seat of operation is the skin in mul- 
tiple abscess formation ; incision should be made and followed by a wet 
dressing of a saturated solution of boric acid, or, if the area is not too 
large, a 1 15000 solution of bichlorid. If the site of the infection is at 
the umbihcus, the suppurating surface should be thoroughly cleansed 
and kept covered with a wet dressing of i : 5000 bichlorid, which 
should be changed at least every two hours. If there is erysipelas, 
an ointment composed of 30 percent ichthyol in vaselin makes the best 
dressing. This should be freshly applied every four hours. The septic 
infant, whether the infection is mild or severe, usually nurses very 
poorly. Oftentimes both breast and bottle are refused. When a 
sufficient amount of fluid is not taken, plain boiled water or sugar- 
water, 5 per cent, or completely peptonized skimmed milk, may be 
given by gavage. If fluids are not given, the child is very apt to de- 
velop inanition fever, which, added to the infection, makes a serious 
condition more serious. From two to four ounces of a normal salt 
4 



50 THK NEW-BORN 

solution used lukewarm, injected into the descending colon through 
a catheter, will often be retained with beneficial results. It should 
not be repeated oftener than once in six hours. 

Medication other than small doses of alcohol — five drops of 
brandy, well diluted, every hour if necessary — has been without 
avail in my cases. The prognosis at best is very grave, although 
when the vital organs are not involved, cases occasionally recover. 

An unusual case of infection which ended in recovery occurred 
in my private practice. The child had no fever, but lost rapidly 
in weight. There was marked prostration. The skin took on a 
greenish hue and we were at a loss to discover the cause of the illness. 
The infection was suspected, but no portal of entry could be found, 
neither could we find any localized process until the nurse discovered 
that the umbilicus and the skin about it were bathed in pus. The 
umbilicus had apparently healed without any indication of local 
trouble. Investigation showed, however, that the infection had 
entered at this site, and extending along the vein or artery, had 
become pocketed and formed an abscess one and one-half inches 
deep. Enlarging the opening at the umbilicus and establishing 
free drainage were followed by a gradual closure of the abscess 
cavity and recovery. 

CEPHALHEMATOMA 
A cephalhematoma is a blood tumor situated between the peri- 
cranium and the exterior of one or more of the bones of the skull. 
The tumors vary considerably in size, are readily recognized, and are 
situated at the site of the caput succedaneum. In a small proportion 
of the cases an internal tumor occurs at the same time, the effusion 
taking place between the dura mater and the skull. Very rarely 
suppuration occurs in the tumor. I have seen two cases of this 
nature, both of which recovered under incision and antiseptic dress- 
ings. If there is an internal effusion the case will be fatal. One of 
these has come under my observation. The usual course, when the 
tumor is external, is for it to be absorbed without treatment. 

ICTERUS NEONATORUM 

Jaundice occurs in about one-third of all infants. It usually 
makes its appearance on the second or third day and lasts from a 
few days, in mild cases, to a week or ten days, in severe. Its effect 
on the child is practically nil At the New York Infant Asylum 
the records show that the icteric infants thrive as well as those who 
are entirely free from the complaint. It is well in these infants to 
keep the intestinal tract active. If the bowels do not move freely, 
twenty drops of castor oil should be given and repeated in twenty-four 
hours, if required. 



UMBILICAL POLYP ATELECTASIS 51 



UMBILICAL POLYP 
An umbilical polyp is usually the result of an overgrowth or an 
outgrowth of a neglected granuloma. The mass, which may vary 
in size from a flaxseed to a pea, is reddened, moist, and usually 
bathed in a viscid muco-purulent secretion. There is often con- 
siderable excoriation of the skin about the umbilical opening. 
Sometimes the mass is so small that it is hidden by the overlapping 
folds of skin, and its presence would not be suspected but for the 
secretion which keeps the parts moist. The polypi are very vascular. 
Cutting the pedicle and applying nitrate of silver or carbolic acid is 
not a safe procedure. I have known severe hemorrhage to follow 
such treatment. About ten years ago I was obliged to sit for three 
hours by the side of a crying, wriggling child making pressure on the 
cut stump of an umbilical polyp, after a colleague had cut the pedicle. 
In no other way could the hemorrhage be controlled. The best 
means of management in these cases is to ligate the pedicle and 
allow the polyp to wither and drop off. The powder referred to 
under the head of Granuloma should be applied after the ligature 
is fixed, and reapplied frequently before and after the polyp has 
dropped off, and continued until the wound. is cicatrized and dry. 

ATELECTASIS 

Atelectasis may be present in the newly born who come into the 
world asphyxiated, and it is not infrequently seen when there has 
been a prolonged difficult delivery. It may be the result of weak- 
ness, pure and simple, and is not of unusual occurrence in the pre- 
mature. For some reason there is a failure or inability to dilate the 
air-vesicles. I have seen sudden collapse occur in marantic infants, 
the child dying in a few moments with cyanosis and orthopnea, 
the autopsy proving the diagnosis of atelectasis. The condition 
may be produced also through compression of the lung with exuda- 
tion in pleurisy or by the obstruction of a bronchus with mucus. 
The most dangerous types are those in which it is present in the 
newly born and when it occurs in the weakly during early life. The 
warning of its presence is usually in the form of cyanosis with rapid 
superficial breathing with or without convulsions. 

The management of atelectasis in the newly born, who come into 
the world asphyxiated because of prolonged difficult delivery or 
when it is the result of weakness, is to make the child cry lustily. 
If auscultation over the lower lobes posteriorly does not show free 
vesicular breathing, the child should be made to cry every day, 
either by spanking, or by plunging him first into water at iio° F. and 
again into cold water at 60° F., our object being to induce vigorous 
crying and thus dilate the air-vesicles. A case under treatment at 
the present time is making satisfactory improvement by inhaling 



52 THK NEW-BORN 

oxygen for one minute out of every fifteen, with stimulation of 
various kinds to make him cry. Atelectasis from obstruction of a 
bronchus or from compression is usually readily relieved when the 
source of the trouble is removed. In out-patient work we occa- 
sionally see marantic young infants in which there is an involve- 
ment of a considerable area of one of the lower lobes posteriorly 
without any sign whatever of discomfort. The process of resolution 
in these cases is very slow, from the periphery toward the center. 
The condition is probably of much more frequent occurrence than 
is generally supposed, if we are to judge from the autopsy findings 
in young infants, particularly in institutions. 

MASTITIS IN THE NEWLY BORN 
Inflammation of the breasts in the newly born, both in the male 
and in the female, is seen with considerable frequency in out-patient 
work. The mammary glands may be swollen to several times their 
normal size and acutely tender. These glands, in young infants, 
should not be pressed nor manipulated in any way, more than is 
required for cleanliness. Not a few of my out-patient cases of 
mastitis have been due to the attempts of the midwife to express 
the milk from the breasts. The cases are explained by the fact 
that the opening of the nipple is large and the gland readily becomes 
infected from unwashed hands or unclean wearing apparel. My 
cases have usually responded well to the application of ichthyol 
25 percent in oxid of zinc ointment, U. S. P. The ointment is 
spread generously upon old linen, which has been boiled and dried, 
and is then gently bound upon the inflamed gland. Over this is 
placed oiled silk to protect the clothing, and, over all, a gauze 
bandage is applied with very light pressure. The dressing should 
be changed and fresh ointment applied every six hours. Wet dress- 
ings in the management of this condition in infants is not advised. In 
four of my cases the mastitis was beyond control when first seen and 
suppuration of the gland — mammary abscess — followed. 

Mastitis in Young Girls. — Inflammation of the mammary 
gland in young girls is a comparatively rare condition, but one of 
sufficiently frequent occurrence to require mention. Swelling and 
tenderness of the breasts are often complained of by young girls 
about the time of puberty, but they subside without treatment if 
let alone. Mastitis is usually due to the entrance of bacteria through 
the nipple, and in its clinical manifestations it resembles mastitis 
in the adult, except that the entire gland is usually involved, becom- 
ing swollen, tender, and excruciatingly painful. Two of these cases 
have been under my care during the past year ; one in a girl of thirteen, 
the other in a girl of seven years. Both cases responded to the use 
of an ice-bag during the acute stage, which was kept constantly 
applied during the waking hours. At night a wet dressing of bichlo- 
rid of mercury, i : 5000, was kept on the infected glands. There 



HEMORRHAGIC DISEASES OF THE NEWLY BORN 53 

was moderate fever, headache, and lassitude in both patients. Each 
was given a sahne laxative in the form of citrate of magnesia, and 
a diet of broth, gruel, toast, and stewed fruit. This diet was con- 
tinued during the period of fever. In one case recovery occurred 
in five days and in the other in seven days. 

Mammary Abscess in Infants. — Mammary abscess is the result 
of a mastitis which failed to undergo resolution. It occurs as fre- 
quently in males as in females. All of my cases were seen in 
institutions or in out-patient work. In four, the abscess developed 
under my own observation. In a female child, a patient at the 
New York Infant Asylum, both glands were entirely destroyed. 
As soon as pus is discovered the abscess should be incised and 
drained, with a view to saving as much of the gland as possible. 
Of course, this advice applies particularly to a female patient. Wet 
dressings are not applicable in cases of young infants when the parts 
covering the thorax or abdomen are involved. It is my custom to 
protect the skin from infection by the use of a lo percent boric 
acid ointment in cold-cream as a base. This is applied on old linen 
about the abscess opening. The dressing should be changed three 
times daily. 

UMBILICAL GRANULOMA 

A granuloma at the umbilicus consists of a reddish secreting 
mass of granulations comprising the umbilical stump. It may 
vary in size from the head of a pin to a pea. Granulomata usually 
occur in cases in which the care of the cord has been neglected. 
In out-patient work they are very frequently seen, and occur usually 
in children who have been delivered by midwives. The mother 
brings the child to the dispensary with the story that the navel 
will not heal. 

The granulations are very vascular and bleed readily. After 
thoroughly cleansing the parts, one or more applications of a 50 per- 
cent nitrate of silver solution, followed by the free use of an absorbent 
dusting-powder, soon produces a normal cicatrix. A powder of 
the following composition is recommended : 

I^. Acidi salicylic! gr. xv 

Acidi borici gr. xxv 

Pulveris zinci oxidi 

Pulveris amyli aa o j 

The powder should be applied very freely at two-hour intervals 
during the day, or at least often enough to keep the wound dry. 

HEMORRHAGIC DISEASES OF THE NEWLY BORN 

A considerable number of these infants have come under my 
observation at the New York Infant Asylum. In describing the 
condition it would seem unnecessarv to continue an irrational 



54 THE NEW-BORN 

nomenclature still in use, based upon the location of the hemorrhage, 
or the name of the physician who is believed to have given the first 
description of a symptom-complex which is supposed to characterize 
the disease. I have seen hemorrhages in the newly born occur from 
nearly every portion of the body and into most of the internal organs. 
In a recent case a colored infant bled to death in the pericranial 
tissues without a sign of hemorrhage elsewhere. I have seen fatal 
hemorrhages from the navel which we were not able to control. In 
one case a hematoma appeared on the dorsal surface of the right foot, 
from which the blood oozed continuously. This, with hemorrhage 
from the intestine, terminated the case in three days. In two cases 
in which the hemorrhage was limited to the gastro-intestinal tract, 
the hemorrhage ceased in twenty-four hours after the administration 
of lactate of calcium in two-grain doses at five hour intervals. This 
treatment is worthy of further trial. Syphilis and hemophilia play 
an insignificant part in causing the hemorrhage. Sepsis is a broad 
term that covers the etiology of these cases. Oftentimes there are 
other proofs of the infection aside from the hemorrhage. Because 
infections differ in degree, nature, and field of action does not neces- 
sarily call for a typical description of each form of infection, and with 
our limited knowledge of the infectious process which may cause the 
hemorrhage, this is impossible at the present time. Without doubt, 
different forms of infection may enter the circulating medium of the 
new-born with a result in hemorrhage. The cases resemble hemo- 
philia in the persistence of bleeding, while infrequently disproving 
its existence by making a complete recovery. The use of styptics and 
astringents for controlling the hemorrhage is useless. The only 
measure that has assisted me in any way has been the application 
of pressure to the bleeding parts, and this is not possible in many 
situations. Adrenalin, locally or by internal administration, has 
not been of any appreciable service. Our best results, which were 
by no means satisfactory, were obtained by attention to the gastro- 
enteric tract and in supplying the best possible means of nutrition. 

Illustrative Case. — One of the most important contributions to 
the literature of hemorrhage in the newborn was reported in the 
Medical Record of May 30, 1908, by Dr. Samuel W. Lambert, of 
New York City. The patient was a girl born at term and weighed 
eight pounds and twelve ounces. Five hours after birth the cord 
was retied because of a slight oozing from the cut end. Twelve 
hours after birth a thickened, dark-colored clot was noticed in the 
right side of the tongue which was thought to be a nevus, but which 
cleared up later, proving that it was a hematoma. Three hours later 
the temperature was 102.2 ° F. The following morning the tempera- 
ture was 102 ° F. The child looked pale and a slight amount of blood 
was found in the mouth. During the day her temperature arose 
to 103° F. and to 104.4° F. the next morning at 2 A, m. She be- 



• HEMORRHAGIC DISEASES OF THE NEWLY BORN 55 

came paler and began to bleed slowly from the nose. A hematoma 
appeared in the scalp behind the left ear. The subcutaneous 
bleeding continued and extended down the neck over the muscles 
across the median line to the other ear, across the coronal suture 
over the frontal bone, and forward under the left ear to the angle 
of the jaw. Blood now appeared in the stools. The bleeding from 
the nose was continuous and quite profuse. During the following 
two days the bleeding continued in spite of the administration of 
calcium lactate and other measures. 

On the fourth day the baby's skin was waxen-white. The mucous 
membranes were colorless. The nasal bleeding continued and the 
case seemed hopeless. Both the vomited matter and the stools 
contained blood, dark colored and bright red. The hematoma on 
the scalp increased and closed the right eye. Kcchymotic spots 
appeared on the legs. 

At this time it was decided to resort to direct transfusion of blood 
from the father of the infant by end-to-end anastomosis of the two 
blood-vessels, after the manner devised by Carrel, of the Rockefeller 
Institute. This was done through the skilful surgical manipulation 
of Carrel himself, and Geo. B. Brewer. " The right popliteal vein 
of the baby was sutured to the left radial artery of the child's father, 
without anesthetic to either patient, and enough blood allowed to 
flow into the baby to change her skin from a pale transparent white- 
ness to a brilliant red color. No measure of the amount of blood 
was possible, but the evidences of a sufficient quantity were manifold. 
She began to cry lustily and to struggle against the bandages which 
held her strapped to an ironing-board. The wound in the leg up to 
this time had oozed a slight amount of pale watery blood, which did 
not clot well. It began to bleed freely and the blood promptly clotted. 
The nosebleed stopped instantly. The pulse became full and strong 
and slowed down, and the respirations were deep and full. As soon 
as the wound was sutured and dressed, the baby was fed an ounce of 
milk, which she took ravenously and retained, and immediately went 
to sleep. 

" Since the ending of the transfusion there has been no hemor- 
rhage, no vomiting, and no diarrhea. Convalescence from the opera- 
tion was uninterrupted except for a slight infection of the wound. 
There was no evidence of hemolytic action at an}" time, and all the 
symptoms of melena ceased at once. The next morning the baby 
was found to be fourteen ounces below her birth-weight. She has 
gained steadily since, and now, eight weeks after birth, she weighs 
ten pounds, fifteen ounces. The hematoma was absorbed rapidly, 
except for a slight discoloration of the upper lid of the right eye, 
which still persists. The stools became of normal character two 
days after the operation. The wound is healed, and the child ap- 
pears to be a normal child of its age to-dav. The striking thing in 



56 THK NEW-BORN 

the case is that the disease ceased suddenly, and the child has been 
cured from the moment of the transfusion of blood." 

After reviewing the literature and commenting on the different 
theories relating to etiology and pathology, Lambert concludes as 
follows : 

" To review the facts of the case: Hemorrhages and fever began 
simultaneously, normal temperature was reached forty hours after 
the onset of fever, but the hemorrhages became progressively worse 
for three days after all fevei had disappeared. At the time of opera- 
tion the baby was in a dying state, and had palpably only a few hours 
to live. Immediately afterward the baby was in perfect health. 
There was no period of convalescence. 

Such a sudden change in condition could not be due to a structural 
regeneration in the capillary vessels nor to a sudden overcoming of 
an infection; clinical experience will permit of no such inference. 
Neither the crisis of a pneumonia nor the relief of a spasmodic croup 
can be compared wtih the observed fact in this case, either from the 
point of view of reversal of pathological condition, or of lapse of time 
necessary to bring it about. 

The only possible explanation of so rapid a change must be 
found in a chemical condition of the blood. And the final conclusion 
as to the nature of the disease is that melena neonatorum is a con- 
genital malformation of the blood of unknown chemical nature. The 
solution of the problem of its etiology is to be found in a chemical 
study of the processes of osmosis in the capillary vessels, of the chem- 
istry of blood coagulation and along kindred Hues, which are for the 
most part new and untouched." 

TETANUS NEONATORUM 

Tetanus in the young infant is fortunately of very infrequent 
occurrence. From the second to the ninth day is the usual period 
of the development of the disease, although it may appear as late 
as the fourth or fifth week. Recovery is the exception. But few 
cases live longer than the second day of the illness. The treatment 
is by the use of sedatives such as chloral and the bromids. One 
grain of chloral every two hours appears to exert some temporary 
benefit. Large doses of bromid of soda — eight to ten grains — ad- 
ministered by the rectum every three hours in mucilage of acacia 
have given good results according to some observers. Tetanus anti- 
toxin has not been used in a sufficient number of cases to estabhsh 
any facts relating to its value. The nutrition of the patient is best 
maintained by the use of peptonized milk given by gavage. 

The cord stump should be cauterized in order to destroy any 
tetanus bacilli which may be present and a wet dressing of i : 5000 of 
bichlorid of mercury kept constantly applied. 



NUTRITION AND GROWTH 

The fundamental principles in the life of the young of all animals 
are growth and development. This statement applies to the young 
of the lower animals as well as to man. Nature has fixed and 
definite laws in accordance with which this growth and development 
proceed. The type of animal produced depends in no small degree 
upon the way we follow out Nature's laws. 

Heredity is, of course, an important factor, but environment 
counts for more. The young of the lower animals or of man may 
possess all that can be desired in the w^ay of heredity, but if the 
early management of his life is faulty, an adult is produced which is 
almost certain to fall short of the normal. On the other hand, 
another, without the benefits of a good heredity, when given the 
advantages of faithful scientific care may produce an adult decidedly 
superior in all respects to those more fortunate in birth. I have 
seen this demonstrated time and again, both in the lower animals 
and in man. From my earliest recollection I have carefully watched 
the growth and development of animals. By observing care as to 
feeding, housing, ventilation, cleanliness, and exercise, I have seen 
animals which promised but little at birth develop into perfect 
mature specimens of their kind. During the past twenty years 
I have been intimately associated with thousands of infants and 
growing children in private, in hospital, and in out-patient work. 
The possibilities of proper growth under good management when 
little was to be expected, judging from the original condition of the 
patient, have been impressed upon me repeatedly. 

The child is here through no choice of his own. He is to have 
a future. His health, vigor, powders of resistance, happiness, and 
usefulness as a citizen are determined in no small degree by the 
nature of his care during the first fifteen years of life. He has a 
right to demand that such care be given him as will be conducive 
at least to a sound, well-developed body, and this should be our 
first thought and object regarding him. Consider for a moment the 
number of occupations, other than the army and the navy, which 
require physical fitness before a candidate is accepted. Competi- 
tion is keen at the present time and will be keener in the future. 
Employers of men and women, whether in the office, the factory, or 
on the farm, cannot afford to employ the physically weak. 

The most important factor in the making of men and women is 
nutrition. It requires no great power of reasoning to appreciate 
the fact that the child who is fed on suitable food will become a 

57 



58 NUTRITION AND GROWTH 

more vigorous, better developed adult than one who, beginning with 
his birth and continuing throughout the entire period of his growth, 
is given only food possessing indifferent tissue-building qualities. 
Next in importance to food, and following in close succession, are 
fresh air, cleanliness, cheerful surroundings, and healthful amuse- 
ments, together with an absence of work of an arduous nature, 
whether in school or at service. That the offspring of man suffers 
more from nutritional errors due to the lack of suitable care than do 
the young of the lower animals is lamentable, but it is a fact never- 
theless. The absence of thought and care and of knowledge relating 
to children is due to the fact that the child as such has apparently no 
intrinsic value in dollars and cents, whereas the young of the lower 
animals are no small part of their owner's material possessions. 

Success in the management of children, nutritionally and other- 
wise, means daily attention to detail. Feeding the child properly 
one or two months out of the year is of little value. He should be 
fed properly every day in the year, for under normal conditions 
every day is a day of growth. Another factor having a deterrent 
influence upon the development of children is their unfavorable 
start during the first year. Unfortunately many mothers cannot 
supply to the infant the nourishment to which he is entitled, and this 
brings us to the matter of substitute feeding, fraught with its per- 
plexities and uncertainties in the most competent hands, and with its 
dangers and disasters with the incompetent and inefficient. In the 
chapter on Substitute Feeding in infants their nutrition is consid- 
ered in detail. It is sufficient to remark here that Nature has 
provided for the baby a food which contains the nutritional elements, 
fat, sugar, and proteid, in fairly definite proportions and in peculiar 
forms. Success in substitute feeding depends upon our ability to 
supply in suitable forms, and the child's ability to assimilate, a food 
containing approximately the quantities of the nutritive elements 
found in human milk. An exact reproduction of mother's milk by 
the use of cow's milk or other food is, of course, impossible. We can 
imitate it, however, with sufficient accuracy to make it an acceptable 
and sufficient food for most children who are deprived of the breast. 
After the nursing or the bottle age, the feeding must not be left to 
the family judgment, for at this rapidly growing period suitable 
nutrition is most important. Left to the family, the diet during 
the second year is very apt to consist of milk, which in large cities 
is often of uncertain nutritive value, together with insufficiently 
cooked cereals, boxed breakfast foods, bread-stuffs, crackers, and 
cake — often procured at the grocer's or baker's. At the out-patient 
departments of the New York Babies' Hospital and the New York 
Polyclinic Medical School only 20 percent of the children treated 
who are over one year of age are of normal development. In those 
under one year of age, only 35 percent are normal. While these 



NUTRITION AND GROWTH 59 

children are not to be considered as representing the country as a 
whole, still they do represent a large part of the population of our 
larger cities. These children are the offspring of day-laborers, 
driyers, waiters, and small wage earners generally. They haye 
been fed in the manner aboye described, not because of poyerty, but 
because of an absence of the slightest knowledge on the part of the 
parents regarding suitability of foods. Their children were not 
hungry, they were fed to satisfy the appetite, but when that was 
accomplished the parents considered their duty done. To feed with 
a definite purpose — with a yiew solely to the physical deyelopment 
of their children — had neyer entered. the minds of the parents, yet 
most of them could read and write and possessed a fair degree of 
general intelligence. They were conyersant with affairs and had- 
attended the public schools, but were absolutely untaught as to how 
they should liye. 

The diet during this period of child life should be highly nutritious, 
and, in order to be properly digested, food should be giyen at definite 
interyals. It should be well cooked and properly seasoned. The 
habit of allowing children to eat between meals cannot be too strongly 
condemned. It not only spoils the appetite for suitable food at 
regular hours, causing children to craye delicacies, but preyents the 
most complete digestion and assimilation. The actiye "runabout" 
child and the school-child require a high proteid diet. It should 
consist of red meat, neyer oftener than once daily, poultry, fish, 
eggs, milk, butter, cream, whole-wheat bread and cereals, such 
as oatmeal, cracked wheat, cornmeal, and hominy. Other cereals 
may be used for the sake of yariety. Each cereal mentioned should 
be cooked three hours the day before using. It may be claimed 
that the prolonged cooking is impossible to secure. It is done, 
howeyer, in dozens of families under my professional care. Green 
yegetables and stewed and raw fruits are important adjuncts to the 
dietary. Dried peas, beans, and lentils in the form of a puree are 
valuable articles of nutrition because of their large percentage of 
vegetable proteid, and they are particularly useful in children with 
a rheumatic tendency, in whom the use of red meat must be curtailed. 
For details in diet at this age, see p. 138. 

Doubtless the next most important factor after food and the 
means of giving it, is good air. It is a just criticism of the average 
American that he is afraid of fresh air, not only by night but by day, 
and it is one of the most difficult features of a child's management 
with which I have had to deal. ^Mothers will feed the children in 
detail according to instruction. They will bathe them and follow 
out to my satisfaction every order and direction. The stumbling- 
block is the open window. If the mother opens it as directed, the 
grandmother or some other member of the famity appears on the 
scene and closes it. The window-board (page 44) and other means 
of ventilation on the market have their uses. The window-board in 



6o NUTRITION AND GROWTH 

my hands has been most satisfactory. It is to be hoped that a 
knowledge of the means and results of treating tuberculosis by 
open-air methods, and the recent agitation concerning the treatment 
of pneumonia and other infectious diseases along similar Hues, may 
so permeate the minds of the masses as to quiet their fears regarding 
dangers of outdoor air. 

In my own experience I have been able to secure an ample supply 
of fresh air either by the window-board, already referred to, or the 
open fireplace. When the child is out of the living-room or nursery, 
the room is ventilated by opening all the windows, when family 
conditions allow, the nursery always being aired in this way. The 
sleeping-room should always be aired for one hour before the child is 
put to bed. Indoor airing (page 37), for which the child is dressed 
as for going out, placed in his carriage or cart, and wheeled up and 
down the room for an hour or two with the windows wide open 
regardless of the weather, is most satisfactory in very young and very 
delicate children, and during convalescence from illness. On very 
inclement days the child accustomed to his daily outing will be greatly 
benefited by the indoor airing. 

With bathing we have less to complain of. The necessity for the 
daily bath is appreciated and acted upon by nearly all classes of 
society. From the time the cord falls and the cicatrix forms, the 
well infant and child should have one tub-bath daily. If he is too 
ill for the tub, he is not too ill to be sponged. The well child is 
naturally good-natured and happy. When such is not the case, 
we have not a well child to deal with. Something is wrong. Often- 
times it is the home management. Adults often forget that exuber- 
ance of spirits and thoughtlessness belong to childhood. Persistent 
child-nagging becomes a habit with many parents and teachers; 
in fact, irritable mothers usually have irritable children. Work 
involving strain, whether physical or mental, should form no part 
of the life of the child. In our modern school system the forcing 
process, the competitions, the giving of rewards of merit, are all of 
them pernicious practices. As a result of the competitive system, 
progress, to be sure, is made along intellectual lines, but at the 
expense of the physical, and what does intellectual attainment count 
for in a weakly or diseased body? A dhild cannot do hard mental 
work, such as is required of many children from the tenth to the 
fifteenth year, and be expected at the same time to develop to the 
best advantage physically. The appetite and digestive powers, the 
capacity for taking and assimilating food, are diminished as a result. 
I have seen it in hundreds of cases. On the streets in New York 
two pictures always fill me with pity — one is the pale, slender school- 
girl struggling home with a load of books. Such a child who came 
to me during the past year had eleven text-book studies besides 
piano and dancing lessons! When the question is asked the child 



GENERAL PROPERTIES OE FOODS 6 1 

or the parents as to the why of all this work and worry and the close 
confinement which it entails, the reply almost invariably is that all 
the girls of her age do the same and she does not want to be behind. 
The other picture is the "little mother," — a pale, wan, tired child 
from seven to twelve years of age who "minds the baby" and the 
other younger members of the household while their mother is away 
from home or at work. Children so abused are happily growing 
fewer, owing to various factors which need not be discussed here. 
It is needless to say that neither type of child makes the ideal woman 
or mother in any station in life. The condition of boys who work 
in factories, sweat-shops, or elsewhere is no better. When too 
much energy is expended in work, it cannot go to the building up of 
a strong normal body. The State is the loser and the child is robbed 
of his birthright. 

It is the duty of physicians having children under their care to 
explain in detail to parents their responsibility as regards the physical 
welfare of their children. Parents, as a rule, are ignorant as to a 
child's management; but they are anxious and wilhng to do the 
best things possible for their children, and will carry out suggestions 
if we take the trouble to enlighten them as to their errors. 

GENERAL PROPERTIES OF FOODS 

Substances used as foods, regardless of the animal which they 
may nourish, possess the common property of being composed of fat, 
proteids, carbohydrates, mineral substances, and water in varying 
proportions. The purposes that these serve in the animal economy 
are essentially the same in all forms of animal life. In order to 
determine the food-value of any substance, a chemical analysis 
which shows the quantities of these nutritional elements is required. 
It will be found that foods varying widely in appearance and physical 
properties are still similar in that they are composed of the same 
food elements, although in different proportions. 

Foods used to sustain animal life in any form must contain the 
ingredients needed by all animals, and they must be present in a 
form suited to the particular kind of animal to be fed, whether it is 
man or one of the lower animals. 

The Ingredients of Foods. — All foods are composed of fat, carbo- 
hydrates, proteids, mineral substance, and water, but these elements 
exist in widely differing forms. Fat may be supplied in meat, 
cream or milk, butter, oleomargerine or butterine, lard, olive oil, 
cod-liver oil, linseed oil, cottonseed oil, etc. Carbohydrates may 
be furnished in the form of cane-sugar, milk-sugar, maltose, and 
dextrose — soluble products derived from starch, cornstarch, wheat 
or other flour, oatmeal, rice, hominy, bread, potatoes, etc. Proteids 
are secured in the form of lean beef, lamb or pork, chicken, fish, the 
gluten of such cereals as wheat and oats, and also in large quantities 



62 NUTRITION AND GROWTH 

from peas, beans, lentils, and other legumes, from the curd of milk, 
and also from eggs. The mineral substances of food are found 
combined with the other ingredients in the form of lime, phosphates, 
magnesium, etc. 

The Function of the Food Elements. — The proteids of the food 
are used to form the bodily structures and to replace tissue consumed 
by the vital processes and excreted as urea. The vital processes, such 
as the circulation of the blood, respiration, and contractions of the 
muscles, call for energy, and this together with bodily heat must be 
supplied by the fats and carbohydrates. The mineral substances 
are used in the formation of bone and teeth, while the water serves 
to dissolve the food elements after they have been digested and to 
carry off waste products. 

The Advantage of a Knowledge of the Composition ot Foods. — 
Inasmuch as each food element has a special function to perform, 
and since growth is impossible without a sufficient supply of these 
nutritional elements, particularly the proteid, it is essential to know 
within reasonable limits the composition of a food, because if the 
elements are not present in proper proportions, disappointing results 
may be obtained from their use which will appear inexplicable, but 
which will readily be accounted for if we know what element of the 
food is at fault. For these reasons it is coming to be the practice, 
in infant-feeding especially, to speak of the percentage composition 
of the milk-foods, as, for example, a food containing 4 percent fat, 
7 percent carbohydrates, 2 percent proteids, and .35 percent min- 
eral substances. Knowing from wide experience the percentage 
of these ingredients generally needed in a food if it is properly to 
nourish a child, it becomes possible to know in an instant whether 
an infant is having a food of suitable nutritive value, by comparing 
its known composition with that established by experiment, as 
requisite. 

The Selection of Food. — In looking over analyses of foods many 
substances will be noticed which, according to their chemical com- 
position, have the same food-value, but which common sense tells 
us are not interchangeable. For instance, no one would attempt to 
feed cracked oats to a human being unless thoroughly cooked, but 
he would give them raw to the lower animals. They will nourish a 
man or the animal equally well, but for man they must be prepared, 
while the horse, for example, can utilize them in their original state. 
This illustrates the importance of adapting food to the consumer. 
Often the question in feeding is not so much, Is the food nutritious? 
as, Can the patient assimilate it? Oftentimes success in infant- 
feeding lies in the physician's ability to discover a form of fat, 
carbohydrate, and proteid which the infant can assimilate. In the 
following pages feeding measures for temporary use will be found 
which may not conform to what some may consider strictly scientific 



GENERAL PROPERTIES OE EOODS 63 

principles; yet they often give brilliant results. Looking a little 
below the surface, it will be found that the measures suggested are 
not unscientific, and that the results are due to applying the fixed 
principles of nutrition in perhaps novel or unusual ways. It is 
usuall}^ best to follow the most direct route to any place, but when 
this is badly blocked, it is better to go another way, if there is one, 
rather than not to arrive at one's destination. 

General Properties of Milks. — When most young animals are 
bom their digestive organs are in a more or less embryonic condition, 
and it is several months before they entirely outgrow this state. 
During this period the nourishment is supplied by the mother 
through her mammary glands, first as colostrum and later as milk. 
When these secretions are analyzed they are found to consist of fat, 
carbohydrates, proteids, mineral substances, and water, and in this 
respect they do not differ from other foods. But the elements exist 
in the secretion in peculiar forms, and the natural inference is that 
in some way they must be particularly suited to animals whose 
digestive organs are still undeveloped. 

The digestive secretions of the stomachs of all known animals 
contain pepsin and hydrochloric acid. In the very young these 
secretions are feeble, but as development proceeds they are much 
more abundant. To understand milk as a food one must know the 
effect upon it of pepsin and acid. When pepsin is added to tepid 
cow's milk it causes the milk to gelatinize, with the formation of curd 
or junket. If the milk is slightly acidified or soured, the curd formed 
is dense and solid and more difficult of digestion. When the milk 
of the cow or the ass or human milk is treated with pepsin and acid 
in exactly the same way, curds totally different are formed, and as 
the human digestive organs are different from those of the cow or 
the ass it is believed that these differences in the digestive properties 
of milks are for the purposes of making the milks suitable for the 
different kinds of digestive tracts. Milks may be regarded as special 
forms of food which require greater digestive effort as the digestive 
secretions of the stomach become stronger, and thus solid food is 
furnished to the developing stomach. It is that portion of the 
proteid of the milk called "casein" that is changed into a solid by 
the pepsin of the stomach. The term casein, however, has been 
loosely applied to all the proteids of all milks. The caseins of all 
milks are not alike in their digestive properties. Therefore the 
mistake of so considering them should be guarded against. A 
consideration of such a modification and adaptation of cow's milk 
as will make it acceptable to the infant's digestive possibilities will 
be found in the chapters dealing with Substitute Feeding. 



64 NUTRITION AND GROWTH 



HUMAN MILK 
While human milk varies as to the proportion of its nutritional 
elements at different periods of lactation, and even at different 
times of the day, milks upon which infants thrive agree within cer- 
tain limits, so that a standard of limitations may be laid down. 
Among a great many specimens which I have examined the solids 
have ranged between 12 and 13 percent. The range in fat has been 
from 2.75 to 4.65 percent, proteid from 0.9 to 1.8 percent, sugar 
from 5.50 to 7.3 percent. These figures represent the analyses of 
the breast-milks given children who were thriving and who were of 
different ages. These variations are not as wide as have been 
reported by others, but it is to be remembered that these were all 
babies who were thriving. Whoever has examined breast-milk 
even a few times is aware of the existence of the widest possible 
variations. I have seen breast-milks which contained 8 percent 
of fat and others which contained only 0.5 percent, but children 
thus fed were not well. Fat exists in mother's milk in minute glob- 
ules as an emulsion. It varies somewhat in composition, depending 
upon the kind of food eaten. 

The proteids of breast-milk offer a wide field for further study. 
There are several of these proteids, the most important being casein 
and lactalbumin. The proportions are subject to considerable 
variation, depending upon the diet and habits of life of the producer. 
With a continuation of lactation there is a diminution of the pro- 
teid, so that at the ninth or tenth month it is considerably reduced, 
the total proteid often being not over i percent. The sugar content 
varies less than does either the fat or proteid, its range of limitation, 
even in milk otherwise poor, being not over 1.5 or 2 percent. 

Directions for nursing well children will be found on page 
62. As to whether the child is getting a sufficient quantity 
of milk may be determined by weighing the baby before and after 
nursing. For this purpose the scales used for weighing children 
should weigh accurately in one-half ounces. The child need not be 
undressed. He is weighed when put to the breast and weighed at 
the completion of the nursing. I have repeatedly found children 
who should get three ounces or more at a feeding who after the 
fifteen-minute nursings had increased in weight but one-half or 
one ounce, showing that only so much milk had been taken. Occa- 
sionally cases have been seen where there was no gain whatever 
after nursing and yet the child was supposed to have been fed. 
In difficult breast-feeding it is well personally to supervise a 
nursing or two, by which means much valuable information may 
be gained. 

Examination of Human Milk. — Milk of the mother is usually 



HUMAN MILK 



65 





c.c 

10 



2_£_8 



5 s_5 



examined to determine whether it contains a sufficient amount of 
fat, sugar, and proteid to nourish the infant ; or to determine whether 
the quantity of one or more of 
the nutritional factors is exces- 
sive or deficient. ^licroscopic 
examination shows us little ex- 
cept the presence of colostrum, 
w^hich usually disappears about 
the ninth da}^ and is to be con- 
sidered abnormal if present 
after the twelfth day. The 
presence of blood and pus may 
also be detected by the micro- 
scope. For an accurate analy- 
sis the milk should be sent to 
a laboratory properly equipped 
for such work. For absolute 
accuracy it is not safe to judge 
from the analysis of one speci- 
men of milk; at least two, 
better three, specimens should 
be analyzed before coming to a 
conclusion. In collecting milk 
for examination the middle of 
a nursing should be selected. 

Laboratory analysis is ex- 
pensive, however, and beyond 
the possibilities of many. For 
out-patient work and those cases 
in w^hich a determination of ap- 
proximate percentages is sufficient I have found the Holt milk set 
(Fig. 7) of great ser\4ce. The set consists of a lactometer and 
two cream-gages. The method of its use is explained by Holt as 
follows : 

"The simplest method is bv the cream-gage. Although its 
results are only approximate, they are in most cases sufficiently 
accurate for clinical purposes. The tube is filled to the zero mark 
with freshly draw^n milk, which stands at room-temperature for 
twenty-four hours, when the percentage of cream is read oft'. The 
ratio of this to the fat is approximately five to three ; thus 5 percent 
cream indicates 3 percent fat, etc. 

"Sugar. — The proportion of sugar is so nearly constant that 
it may be ignored in clinical examinations. 

" Proteids. — We have no simple method for determining clinically 
the amount of proteids. If we regard the sugar and salts as con- 
stant, or so nearly so as not to affect the specific gravity, we may 
5 



10^ 



Fig. 7.— The Holt Milk Set. 



66 



NUTRITION AND GROWTH 



form an approximate idea of the proteids from a knowledge of the 
specific gravity and the percentage of fat. We may thus determine 
whether they are greatly in excess or very low, which, after all, is 
the important thing. The specific gravity will then vary directly 
with the proportion of proteids, and inversely with the proportion 
of fat — i. e.y high proteids, high specific gravity; high fat, low specific 
gravity. The application of this principle will be seen by reference 
to the accompanying table. ^ 





"WOMAN'S MILK 






Specific Gravity, 70° F. 


Cream — 24 Hours. 


Proteid (Calculated). 


Average 


1.031 


7 percent. 


1.5 percent. 


Normal varia- 








tions 


1.028-1.029 


8 percent- 12 


Normal (rich milk). 


Normal varia- 




percent. 




tions 


1.032 


5 percent-6 


Normal (fair milk) . 


Abnormal varia- 




percent. 




tions 


Low (below 1.028) 


High (above 10 


Normal (or slightly be- 


Abnormal varia- 




percent). 


low). 


tions 


Low (below 1.028) 


Low (below 5 


Very low (very poor 


Abnormal varia- 




percent) . 


milk). 


tions. 


High (above 1.032) 


High. 


Very high (very rich 


Abnormal varia- 






. milk). 


tions 


High (above 1.032) 


Low. 


Normal (or nearly so). 



"Any specimen taken for examination should be either the 
middle portion of the milk — i. e. , after nursing two or three minutes — 
or, better, the entire quantity from one breast, since the composition 
of the milk will differ very much according to the time when it is 
drawn. The first milk is slightly richer in proteids and much poorer 
in fat." 



MATERNAL NURSING 
Writers on this subject are very apt to state that the ability of 
the mother, particularly among the well-to-do, to fulfil this most 
important function is surely decreasing. This may have been a true 
statement a decade ago; at the present time, however, 1 am sure it 
is erroneous. In my own medical life I have seen a change for the 
better, particularly during the past five years. The young mother 
of today is better able to nurse her offspring than was her sister five 
or ten years ago. I attribute this to the fact that the youth of the 
present day are more vigorous, more nearly normal individuals than 
were those of a decade ago. The inability to perform the nursing 
function so that it will be successful has always been attributed to 
the mother per se. This, I think, is an error. Not every breast- 
milk for two or three weeks after parturition is ideal, as I have found 

^The Holt apparatus may be obtained from Eimer & Amend, Eighteenth 
Street and Third Avenue, New York. 



MATERNAL NURSING 67 

by the examinations of hundreds of them. If a child is born with 
a generally enfeebled vitality, it keenly feels any slight abnormality 
in the milk, or it may not be able to digest perfectly normal milk; 
in either event, the milk disagrees and the nursing is discontinued. 
Breast-milk during the first two or three weeks of the infant's life 
is produced under conditions which are unfavorable — conditions 
which do not indicate the possibilities of the breast as a secreting 
organ. Following, as it does, upon the stress of confinement, it is 
not indicative of what may be possible later when the customary 
life and daily habits are resumed. Repeatedly I have found a very 
high fat or a high proteid, or both, during the first week or two, 
entirely corrected later without interference. This condition at 
the time was considered sufficiently serious to warrant the discon- 
tinuance of nursing on the part of a weakly infant, while in a vigorous 
infant it would be entirely ignored. 

The change which enables more mothers successfully to nurse 
their infants is due to two causes — more vigorous fathers and mothers 
and more vigorous offspring. Following this line of reasoning, the 
more normal the mother, the better able is she to perform this 
normal function. That this is the case is due, I believe, to the fact 
that growing girls and young women are leading more hygienic 
lives than formerly. The making of golf, bicycle and horseback 
riding, boating, and automobiling popular and fashionable — in short, 
the taking of girls out of doors and keeping them there a consider- 
able portion of the day — has worked a marA^elous change for the 
better, both physically and mentally. A neurotic mother makes 
the poorest possible milk-producer. Proportionate to the population, 
there are fewer neurasthenics among the young women today than 
there w^ere ten years ago, and there will be still fewer ten years hence. 
At the present time the timid, retiring young woman of the neuras- 
thenic type is not popular in her set. It is a fortunate thing for the 
future of the human race, at least for that portion of it which resides 
in the United States, that the young woman has transferred her alle- 
giance from the crochet and embroidery needle to the golf club. It 
may be said that our argument holds only with the wealthy or the 
well-to-do. Imitation is one of the strongest characteristics of the 
human race, and this tendency in America to outdoor hygienic living 
pervades all classes. Saturday half-holidays, the excursions and 
outings afforded by reduced rates in transportation, are much more 
popular than they were ten years ago. Food is better selected and 
better prepared, owing to increased knowledge on the part of the 
people as to what constitutes proper nutrition. These are facts, 
in spite of the sensational novelists and magazine-writers. 

A feature which marks an important advance in the right direction 
is the establishment of a department in dietetics and food economics 
in the New York Training School for Teachers. The Dean, Dr. James 



68 NUTRITION AND GROWTH 

E. Russell, in establishing this course is producing benefits which per- 
haps are more far-reaching than he realizes. The students are taught 
food values, food preparation, and food economics, which consists in 
providing for a given amount of money the most nutritious food in its 
most attractive form. Hundreds of teachers are sent out from this 
institution every year to take their places of usefulness as instructors 
of the young in all portions of the country. Each has learned some- 
thing of food values, and, better still, each has had impressed upon 
him or her the importance of the proper nutrition of a growing 
child. They are taught that, without this, the best possible type 
of adult cannot be produced. As a result of such instruction they 
will be of far greater service in their fields of labor ; for not only can 
they teach what is laid down in the books, but, what is equally if 
not more important, they are competent to teach those under 
their care how to live; and those who live properly, grow properly, 
following out the maxim of Herbert Spencer that "the first requisite 
for success in life, is to be a good animal ; and to be a nation of good 
animals, is the first condition of national prosperity." It may be 
thought that we have wandered far from our . subject — maternal 
nursing, but such is not the case ; for conditions which relate to this 
important function, even remotely, demand our respectful consid- 
eration. The food and care of the growing girl have the most intimate 
bearing upon her future life, and if she is to be called upon to per- 
form the most important function of womanhood, she surely has the 
right to demand that she receive during her girlhood proper prepara- 
tion, which heretofore has too often been denied her. 

It is not pleasant to criticize physicians ; but friendly criticism 
should always be welcomed. The family physician does not, in a 
great majority of instances, fulfil his function, or extend his field of 
usefulness to its full capacity, his conception of duty too often in- 
cluding only the sick. Unsought advice as to the feeding and daily 
habits of a child's life, I find are usually welcomed and appreciated by 
the parents. In practically every instance, according to my obser- 
vation, errors in a child's management are due to ignorance. Parents, 
no matter what their station in life, are glad to do what is for the best 
interests of their children when it is made clear to them. It is our 
duty to take parents into our confidence and explain to them the 
reasons for the line of action advised. When they appreciate the 
reason for certain procedures, I find that they are far more apt to 
follow them. I am confident from observations upon many cases 
that if I could have the physical direction of ten average girls in any 
station in life, provided that they could have the benefit of fresh 
air and good food from infancy to adolescence, successful nursing 
mothers could be made out of eight of them. Certain rules of 
life having a direct bearing on nursing lead us nearer the ideal and 
may enable one who otherwise could not nurse her child to do so 



I MATERNAL NURSING 69 

successfully. These requirements, it will be seen, are laid along 
common-sense lines and cause no hardship or mental distress — one 
of the chief requirements of a nursing woman being that she shall 
be mentally normal. 

There are few conditions in which we are called to act so variable 
and so uncertain as is the production of breast-milk. Breast-milk 
is one of the most precious substances. It is invaluable unless we 
can put a value on human life. The most successful nursing age is 
between the twentieth and thirty-fifth years. I have, however, 
seen it successfully cariied on in a girl of fourteen, in a woman of 
fifty-two, and in the much abused society girl, while I have seen 
it fail absolutely in peasant women fresh from the fields of Hungary 
and Bohemia. I have seen those in whom at first the nursing was 
most unsatisfactory, develop into perfect nurses. 

vSome mothers will be able to carry on the nursing for onh^ two 
months ; others, three, five, seven, or nine months. In my experience 
whether in out-patient or in private practice, it is extremely rare 
for the breast-milk to be sufficient for a child after the ninth 
month. 

The following can be laid down as nursing axioms : 

A diet similar to what the mother was accustomed to before the 
advent of motherhood should be taken. 

There should be one bowel evacuation daily. 

There should be from three to four hours daily spent in the open 
air with exercise which does not fatigue. 

There should be at least eight hours' sleep out of every twenty- 
four. 

There should be absolute regularity in nursing. 

There should be no worry and no excitement. 

The mother should be temperate in all things. 

The Diet. — I have many times been consulted by nursing mothers 
because the nursing w^as unsuccessful or a partial failure, and have 
found that their diet had been restricted to an extreme degree. 
To put on a greatly restricted diet a robust young mother who has 
always eaten bountifulh^ of a generous variety of foods is one of the 
best means of curtailing the quantity and lowering the quality of 
her milk-supply. AVhen asked to prescribe a diet I tell them to eat 
practically as they were accustomed to before the advent of preg- 
nancy and motherhood. That this particular vegetable or that par- 
ticular fruit should be forbidden on general principles is a fallacy. 
Food that the patient can digest without inconvenience is a safe 
food so far as the nursing is concerned, as may readily be determined 
in any given case. If a wide range of diet is prescribed in some 
individuals, a plain, more or less restricted diet is desirable in others. 
This must be remembered in the management of the wet-nurse 
(page 81). Many a wet-nurse who has been carefully selected, 



70 NUTRITION AND GROWTH 

who to the best of our judgment should prove satisfactory, utterly 
fails in a few days to fulfil the duties of the office for which she was 
chosen. In not a few instances the failure is due to a very full diet 
of unusual articles of food, the existence of which, in many instances, 
she never dreamed of. Indigestion and constipation follow, and 
both the nurse and the baby are made ill and the woman's usefulness 
ceases. A woman who has lived and kept well on the diet and food 
found in the home of the laboring-man, whether in the city or country, 
will make a far better wet-nurse on this diet than if she indulges in 
food to which she is entirely unaccustomed. The diet of a nursing 
mother, then, should in general be that to which she has been 
accustomed. 

Nursing is a perfectly normal function, and a woman should 
be permitted to carry it out along only natural lines. Inasmuch as 
there are two lives to be provided for instead of one, more food, 
particularly of a liquid character, may be taken than she may have 
been accustumed to. It is my custom to advise that milk be given 
freely. A glass of milk may be taken in the middle of the afternoon 
and eight ounces of milk with eight ounces of oatmeal or cornmeal 
gruel at bedtime, if it does not disagree with the patient. Our only 
evidence that a food is not disagreeing is the condition of the digestion. 
When any article of food disagrees with the mother, or if she is 
convinced that it disagrees, whether or not such is really the case, 
the food should be discontinued. In a general way, milk in quan- 
tities not over one quart daily, eggs, meat, fish, poultry, cereals, 
green vegetables, and stewed fruit constitute a basis for selection. 
The method of preparation for the different meals is not arbitrary. 

The Bowel Function. — A very important and often neglected 
matter in relation to nursing is the condition of the bowels. There 
must be one free evacuation daily. For the treatment of constipa- 
tion in nursing women I have used different methods in many cases. 
The dietetic treatment does not promise much. For here, again, 
manipulation of the diet may interfere with the milk production. 
Three methods are open to use — massage, local measures, and drugs. 
Massage is available in comparatively few cases. ^ Local measures 
consist in the use of enemas or suppositories. Every nursing woman 
under my care is instructed to use an enema at bedtime if no evacua- 
tion of the bowels has taken place during the previous twenty-four 
hours. Many out-patients, in whom constipation is very prevalent, 
indulge in excessive tea-drinking, taking often from one to two 
gallons of tea daily. In such patients where an absolute discon- 
tinuance of the tea-drinking is often impossible and not absolutely 
necessary, I usually allow two cups a day. For a laxative in such 
cases and in many others, a capsule of the following composition 
has served me well: 



MATERNAL NURSING 7 1 

I^. Extract! belladonnae gT^. i 

Extract! nuc!s vom!c8e gr. \ 

Extract! cascarae sagradae gr. v 

M. et ft. capsula No. j. 

Sig. — To be taken at bedt!me. 

The amount of the cascara sagrada may be varied as the case may 
require. In not a few instances I have found it necessary to give 
two capsules a day in order to produce the desired result. Neither 
the belladonna, the nux vomica, nor the cascara appears to have 
any appreciable eifect on the child. 

Air and Exercise. — Outdoor life and exercise are desirable here 
as they are under all other conditions. In a nursing woman with 
her added responsibility, they are doubly so. In order to get the 
best results, exercise or work should so be adjusted as not to reach 
the point of fatigue. The mother w^hose nights are disturbed should 
be given the benefit of a midday rest of an hour or two. She 
should have at least eight hours' sleep out of every twenty-four. 
Certain annoyances, anxieties, and w^orries are inseparable from the 
life of every child-bearing woman. It should be our duty, however, 
to explain to the mother and to other members of the family that an 
important element in satisfactory nursing is a tranquil mind. Dur- 
ing the lactation period she should be spared all unnecessary care 
and petty annoyances. 

Regularity in Nursing. — The breast which is emptied at definite 
intervals invariably works better than does one which is not, not 
only as regards the quantity, but the quality of the milk as well ; 
so that system in breast-feeding is almost as essential to milk- 
production as to its digestion and assimilation. 

After it is demonstrated that the nursing is progressing satis- 
factorily as proved by the satisfied, thriving child, I begin with one 
bottle-feeding daily. The advisability is obvious; in case of illness 
of the mother, if she is called away from home, or if, for any reason, 
the child cannot have the breast, the feeding is provided for. An- 
other advantage is that it gives the mother needed freedom from 
restraint. She is thus enabled to have the benefit of a change of 
scene. Amusements and recreations which the invariable nursing 
period denies her can be indulged in. As a result of this greater 
freedom, she is able to supply better milk and to continue nursing 
longer than if tied continually to the baby, no matter how fond she 
may be of it. 

Frequency of Nursings. — The new-born infant is entitled to 
ten nursings in twent3^-four hours. From 6 a. m. to lo p. m., 
inclusive, there should be nine nursings. There may be one nursing 
at 2 or 3 A. M. As the child becomes older less frequent nursings 
are required. The following table will be found useful in this 
connection : 



72 NUTRITION AND GROWTH 

3d to the 21st day 10 nursings. 



3d 

6th 
3d 
5th 
7th 



6th week 9 

12th week 8 

5th month 7 

7th month 6-7 

1 2th month 5-6 



Giving of Water. — From one-half to one ounce of a i percent 
solution of milk-sugar should be given the infant every two hours 
until the milk appears in the breast. Otherwise there will be unnec- 
essary loss in weight and perhaps a high degree of fever due to 
inanition. 

If the child is restless and uncomfortable, it is safe to conclude 
that he is thirsty, and one ounce of the sugar-water will usually 
satisfy him. With the commencement of nursing, accustom the 
baby to getting his food at regular intervals. 

Signs of Successful Nursing. — The child shows a gain of not less 
than four ounces weekly. This is the minimum weekly gain which 
may safely be allowed. When a nursing baby remains stationary in 
weight or makes a gain of but two or three ounces a week, it means 
that something is wrong, and it will usually, but not invariably, be 
found in the milk-supply. When the baby is nursed at proper 
intervals and the supply of milk is ample and of good quality, he is 
satisfied at the completion of the nursing. If he is under three 
months of age, he falls asleep after ten or twenty minutes at the 
breast. When the nursing period again approaches, he becomes 
restless and unhappy, crying lustily if the nursing is delayed. When 
the breast is offered, he takes it greedily. The stools are yellow 
and number from two to three daily. The weekly gain in weight 
under such conditions is usually from six to eight ounces. 

Signs of Unsuccessful Nursing. — Theoretically, every normal 
breast baby should be a thriving, well baby. That such is not the 
case, is an unfortunate fact. The standard established for a well 
baby is not upheld here. When the supply of milk is scanty the 
child remains long at the breast and cries when he is removed. He 
shows signs of hunger before the nursing hour arrives. A cause of 
failure in breast-feeding, and probably the most frequent cause, is 
a scanty milk-supply. The chief nutritional elements in mother's 
milk are fat, 3 to 4 percent; sugar, 7 percent; proteid, 1.5 percent. 
Failure may be due to a marked disproportion of these elements 
which may cause sufficient indigestion and resulting loss in weight 
to necessitate a discontinuance of nursing. Thus there may be a 
high fat — from 5 to 6 percent; or very low fat — from i to 1.5 per- 
cent. In the high-fat cases there will usually be diarrhea with green, 
watery stools. The child strains a great deal and there are green 
stains on many of the napkins. In high-fat cases there is also regur- 
gitation or vomiting of sour material. The fat-globules may readily 
be made out if the vomited material is placed under a low-power 



MATERNAL NURSING 73 

microscope. Low fat means deficient nourishment and may cause 
constipation. Sugar is rarely a cause of trouble in nursing babies. 
It seldom varies, ranging from 5 to 7 percent in the great majority 
of breast-milks. Young children, further, have a marked toleration 
for it. The proteid of mother's milk is the most frequent cause of 
nursing difficulties. Like the fat, it may so be decreased that 
nutritional disorder may be induced in the patient, or it may be 
very much increased, the latter being usually the cause of colic or 
constipation in otherwise healthy nursing infants. In such infants 
curds may be found in the stools, the passage of which is always 
accompanied by a great deal of gas. The milk may contain the 
normal percentage of fat, sugar, and proteid, but be scanty in 
amount. Instead of the four or five ounces to which the child is 
entitled, he may get but one or two ounces. Whether or not the 
quantity is sufficient, can be determined by weighing the baby 
before and after each nursing for twenty-four hours. One ounce of 
breast-milk weighs practically one ounce avoirdupois. The quality 
or strength is determined by an examination of the milk itself 
(page 64). Before nursing, the child is put in the scales without 
undressing him and the weight noted. He is allowed to nurse 
fifteen minutes. He is then removed from the breast and weighed. 
A child under one week old should gain from i to i^ ounces; at 
three weeks of age, i^ to 2 ounces; four to eight weeks of age, 2 to 
3 ounces; eight to sixteen weeks of age, 3 to 4 ounces; sixteen to 
twenty-four weeks of age, 4 to 6 ounces; six to nine months of age, 
6 to 8 ounces; nine to twelve months of age, 8 to 9 ounces. Of 
course, arbitrary limits cannot be fixed as to the quantity. 

Stationary weight or loss in weight with a dissatisfied child usually 
means defects in quantity which are readily proved by the weighing. 
To be fed at the breast may also cause the child to suffer from an 
excess of good milk, in which event there will be vomiting or regurgi- 
tation, usually associated with colic. When this overfeeding con- 
tinues, dilatation of the stomach develops, vomiting becomes 
habitual, the child loses in weight, and the breast-milk is said not 
to agree, and often, unfortunately, the baby is weaned. This has 
been the outcome in scores of cases. When there is habitual vomit- 
ing and colic in a nursing baby, two things are to be done — the 
baby must be weighed before and after nursing, and the milk must 
be examined. 

I have repeatedly treated children for indigestion who were 
entirely relieved by shortening the nursing period. Weighing the 
baby at intervals of from three to five minutes and noting the gain 
has shown tha^t the three or four ounces which may be the child's 
stomach capacity were obtained in two, three, or five minutes, the 
excess which the child took over this amount being the cause of his 
trouble. Given a free, full breast and a vigorous nurser, and one 



74 NUTRITION AND GROWTH 

ounce will be taken in one minute. When the nursing "gait" is 
established, a child should be kept up to the schedule. There are 
few more pernicious teachings than that a baby should be allowed 
to nurse when he wants to and as long as he wants to. The idea 
that a nursing infant will take no more than is good for him is the 
fruit of inexperience. Recently a mother consulted me in regard to 
putting her one-month-old baby on the bottle, as he had many green 
stools, cried a great part of his waking hours, and weighed but a few 
ounces more than at birth. Her milk was supposed to be ''too 
strong" for the child. An examination of the breast and a talk with 
the mother satisfied me that the breast-milk was not at fault. An 
examination of the milk proved it to be good average milk — 3.5 
percent fat, 6 percent sugar, 1.45 percent proteid. A one day's 
test by weighing was decided upon. He was allowed to nurse one 
minute and rest one minute. During the resting period he was 
weighed. Weighing and resting him in this way, it was found that 
in three minutes he got from 3 to 3 J ounces of milk. The nursing 
was then reduced to three minutes on one breast and five minutes 
on the other, which was the "slower" breast of the two. Every 
sign of indigestion promptly disappeared after this change. The 
stools became normal and the infant made a satisfactory gain in 
weight of one ounce daily. 

The quantity may be suitable for the age of the child, he may 
not vomit or show a sign of indigestion, and yet he may not thrive. 
In such a case an examination or repeated examinations of the milk 
at intervals of two or three days will usually show that it is poor, 
below the normal perhaps in both fat and proteid. Such a case 
occurred in the New York Infant Asylum. A Swedish woman was 
admitted with an infant two months old in fair condition. She had 
an abundance of milk and asked for a foster-child, so great was her 
discomfort from the excessive flow of milk. The weekly weighings 
of the children soon revealed that there was no growth, and after 
a few weeks both children upon examination showed developing 
rickets. The milk was then examined and was found deficient — 
fat 1.2 percent, sugar 5 percent, and proteid 0.73 percent. 

Signs of Insufficient Nursing.— The baby remains long at the 
breast, perhaps one-half to three-quarters of an hour. When re- 
moved, he is restless and uncomfortable. After a short time, in an 
hour or less, he is very hungry and demands frequent nursings day 
and night. 

Management of Abnormal Milk Conditions. — When it is found 
that the breast-milk is too strong or too weak, or when the normal 
ratios of fat, sugar, and proteid are not maintained, it may be 
possible to increase or diminish the milk strength. It may also be 
possible to increase either the fat or the proteid when desirable. 
The heavy milk will usually be found in mothers who are robust. 



MATERNAL NURSING 75 

who eat heartily, and who take but Httle exercise. In such a mother, 
the prescribing of a plain diet, allowing red meat but once a day, 
discontinuing the mialt liquors or wine, — which it will often be found 
that she is taking, — and directing that she walk a mile or two a day, 
will frequently bring the milk to digestible proportions. In some 
cases, however, this will not be successful, and the colic, constipation, 
and vomiting continue, even though the quantity obtained at each 
nursing is within normal limits. In some mothers it will be impos- 
sible to change the mode of life, except perhaps as to the discon- 
tinuance of alcohol. When such conditions prevail, the mother's 
milk may be modified by giving from one-half to one ounce of boiled 
water or plain barley-water before each nursing. This is a procedure 
to which I frequently resort. One teaspoonful of lim.e- water added 
to one ounce of water before each nursing has made the breast -milk 
agree when otherwise it would have been impossible. AA'hen the 
milk is deficient both in fat and proteid, a diet composed largely 
of red meat, poultry, fish, rye bread, or whole-wheat bread, oatmeal, 
cornmeal, with two or three pints of milk daih', will often be followed 
by an increase both in fat and proteid. The use of alcohol in moder- 
ate amounts, in the form of malt liquors or wine, will usually increase 
the fat. I have frequently seen it advance 2 percent in from two 
to three days. Disappointments in improving the quantity or 
quality of the breast-milk, however, are frequent. 

In addition to the one bottle which, for reasons above mentioned, 
is given early in the child's life, I find it necessary at the seventh 
month to add an extra bottle or two. Usually at this time the proteid 
in human milk begins to diminish in quantity, and as this is the 
most important nutritional element, an insufl&cient quantity at this 
rapidly growing period of life is a matter of no little importance. 
At the twelfth month, with very few exceptions, my nursing babies 
are weaned from necessity. At this age exclusive breast-nursing, if 
one consider the best interests of the child, is practically out of the 
question. Out of many thousands of mothers I recall but one 
instance where a mother was able successfully to nurse her child 
after the twelfth month. This remarkable woman, a mother of 
six children, had nursed every one of them exclusively up to the 
fifteenth or the eighteenth month. 

Mixed Feeding. — AA^ith a diminution in the amount of milk 
secreted, the breast-milk must, of course, be supplemented by 
modified cow's milk. This method of feeding is usualh' successful. 
If the mother of a six-months-old baby can satisfactorily nurse him 
three times in twenty-four hours, he is given, in addition, three 
bottle-feedings, in this way supplementing the mother's milk. It 
is best when using mixed feedings to alternate the breast and the 
bottle. The modified milk strength should be that which is suitable 
for the average child of his age. (See Infant-Feeding, page 83.) 
In beginning the use of cow's milk, however, it must be remembered 



76 NUTRITION AND GROWTH 

that at first a weaker strength must be used than the child will re- 
quire for growth, this weaker food being necessary in order gradu- 
ally to accustom him to the change. If too strong a cow's-milk 
mixture is given at first, it will be very apt to disagree, causing 
colic and vomiting. Later, when the child has become accustomed 
to the new food, a stronger mixture may be given. When a mother 
cannot give her infant at least two satisfactory breast-feedings daily, 
it is better to wean the child. 

Maternal Conditions under Which Nursing is Forbidden. — When 
the mother has tuberculosis in any of its various forms or manifesta- 
tions, whether it involves the glands, the joints, or the lungs, breast- 
feeding is to be forbidden. In epilepsy and syphilis nursing is 
likewise forbidden. In nephritis and malignant disease of any 
nature, and in chorea, nursing should be discontinued. Women 
who are rapidly losing weight should not be allowed to continue 
nursing their infants. In case of serious illness of any nature, such 
as typhoid fever, pneumonia, or diphtheria, and upon the advent 
of pregnancy, nursing should be stopped. 

Care of the Breasts during Weaning. — When the breast-feeding 
is carried on the usual length of time, — from nine to twelve months, — 
the process of weaning ordinarily causes little or no discomfort. All 
that is usually required is to press out enough of the milk to relieve 
the patient as often as the breast becomes painful, which may not 
be more than two or three times a day. When the weaning is 
necessarily abrupt, no little discomfort may result. If there is a 
free flow of milk, which is apt to be the case w^hen the weaning must 
take place in the early nursing period, tightly bandaging the breasts 
is required. When localized hardened areas occur in the glands, 
they should be massaged until softened, and the bandage reapplied 
and worn until the secretion ceases. When the weaning can more 
gradually be done, the best way is to give one less nursing every 
second or third day until only two are given. After this has been 
practised for one week, these also can be discontinued. In cases 
where sudden weaning is required, a saline laxative, such as citrate 
of magnesia or Rochelle salts, should be given every day for five 
days — sufficient to produce two or three watery evacuations daily. 
In the mean time the mother should abstain from fluids of all kinds 
up to the point of positive discomfort. 

Conditions Which may Temporarily Produce an Unfavorable 
Effect upon the Breast-milk, but not Necessitate the Discontinuance 
of Nursing. — The advent of the first menstruation period particularly, 
and in some cases of every menstruation period, is attended with an 
attack of colic or indigestion on the part of the child, rarely sufficient, 
however, to necessitate the discontinuance of the nursing even for 
a single day. 

Factors influencing the mental conditions of the mother, such 
as anger, fright, worry, shock, distress, sorrow, or the witnessing of 



MATERNAL NURSING 77 

an accident, may affect the milk secretion sufficiently to cause no 
little discomfort to the child, and oftentimes the temporary lessening 
of the flow for a day or two. The influence of the mental state upon 
the character of the milk was early brought to my attention while 
resident physician at the County Branch of the New York Infant 
Asylum. In this institution there were usually about two hundred 
nursing mothers, the majority of them from the lower walks of life, 
at least 95 percent of the infants being illegitimate. The necessity 
of placing a considerable number of these mothers in wards, and 
their living thus in close contact, gave rise to rather frequent disputes, 
and not infrequently to fistic encounters of a decidedly vigorous 
character. After a particularly active disturbance, several nursing 
infants in the ward would be taken suddenly ill, usually with vomit- 
ing, diarrhea, and fever. When two or more infants were thus 
discovered ill, we soon learned to know the cause w^hen inquir}^ or 
evidence furnished by hasty inspection of the mother showed that 
she had been particularly active in the affair. A small proportion 
of the mothers were from the better walks of life. Letters of for- 
giveness or reproach or visits 
of a like nature from fathers, 
mothers, or sisters, have 
brought many a sick baby 
to my attention and caused 
me many anxious moments. 
Conditions Which call for 
Temporary Discontinuance 
of Nursing. — During an acute 
illness with fever, such as 
indigestion, tonsillitis, and 
minor illnesses of a like na- 
ture, nursing should be dis- 
continued for a day or two. 
When the infant is removed 
from the breast, it should be 
our effort to maintain the 

flow of the milk. This is Fig. S.-Nipple-shield. 

best done by emptying the 

breast with a breast-pump (page 79) at the usual nursing period 
until the time arrives when the nursing may be resumed. In such 
conditions the advantage of having the baby accustomed to one 
bottle a day will at once be appreciated. 

Care of the Nipples. — Six hours after delivery or confinement 
the nipples should be washed with a saturated solution of boric acid 
and the child put to the breast and nursing attempted. After this, 
the attempts at nursing should be repeated every four hours, although 
the milk does not appear in the breasts until from forty-eight to 
seventy- two hours after the birth of the child. Colostrum may be 




78 NUTRITION AND GROWTH 

present, which is useful as a laxative and may satisfy the child. A 
further advantage of the nursing at this time is that it gradually 
accustoms both the nipple and the infant to what will be required 
of them later. Immediately after the nursing, the nipple should 
be carefully washed with a saturated solution of boric acid and 
thoroughly but gently dried. A baby should never be allowed to 
nurse on a cracked or fissured nipple. For this very painful con- 
dition a nipple-shield (Fig. 8) should always be used. 

CRACKED AND FISSURED NIPPLES 

Fissures of the nipples are often the result of lack of care 
and cleanliness. Nipples that are not washed and dried, but 
allowed to remain moist after nursing, particularly during the 
first few days, are also very apt to become macerated and cracked. 
In the cases in which there is a tendency for the breasts to "leak," the 
milk decomposes on the nipples, and in addition to the maceration, 
the nipple is excoriated by the acids formed by the decomposition 
in the milk. Leaking nipples should be kept covered with pads of 
sterile absorbent gauze. Cracks and fissures in the nipple may be 
sufficiently painful to prevent a continuance of the nursing. In 
getting the histories of not a few bottle babies, I have been told 
that nursing had been stopped because of cracked nipples. The 
prevention and successful treatment of the condition, therefore, is 
a matter of no little importance. A strong child tugging on a 
fissured nipple may be an excruciatingly painful process for the 
mother, and when the fissures are not healed, it. can readily be 
understood that the pain accompanying and the dread of nursing 
may produce sufficient mental distress to change the character or 
stop the flow of the milk, either of which may require that the 
nursing be discontinued. 

Treatment. — The treatment which gives the best results, and 
which is used exclusively at the New York Infant Asylum and 
Maternity, is to bathe the parts with a saturated solution of 
boric acid after each nursing, dry the nipple, and apply a pad 
of sterile gauze. Once or twice a day, the cracks or fissures are 
painted with an 8 percent solution of nitrate of silver. There is no 
pain attending this application. The pad of sterile gauze just 
referred to is placed over the nipple and held in position by a binder 
sufficiently tight to support the breasts. Before the next nursing 
the nipple is bathed with sterile water and the infant takes the 
breast as usual. If there are deep fissures, it may be well for a day 
or two to use a nipple-shield (page 77). Another important reason 
for a rapid healing is the danger of infecting the gland through the 
open nipple wound — the usual cause of mammary abscess. The use 
of an ointment to the nipples is not advised, for the reason that it is of 
little or no service ; in fact, in most cases ointments do harm because 
they soften the epithelium and make the nipple tender. 



DEPRESSED NIPPLES 79 

CAKING OF THE BREASTS 

Caking of the breasts is very apt to occur during the first few 
days of nursing. The milk, when it appears in the breasts, is often 
secreted in large amount. A great deal more is supplied than the 
child, with its small stomach and usually indifferent nursing, is able 
to digest. The breasts should be watched very carefully during 
this time so as to guard against the possibility of the milk remaining 
undrawn, with the resulting harm. After the completion of the 
regular nursing, if a considerable amount of milk remains in the 
breasts, it should be drawn by the breast-pump (Fig. 9) and the 
breast thus relieved. 

Treatment. — When nodules form, they may readily be soft- 
ened by gentle massage. Lanolin should be used on the fingers 
so as to avoid unnecessary irritation of the skin. The massage 
should be repeated as often as the nodules appear. The caking is 
more apt to occur in the dependent portion of the glands. The 
so-called pendulous breasts, which may show a tendency to cake, 
should be supported by a binder lightly applied. 

DEPRESSED NIPPLES 
Not an infrequent source of difficulty in the management of the 
nursing function in a primipara is depressed nipples. The child 




Fig. 9.— English Breast-pump. 

cannot get a sufficient hold to make suction possible. He thus 
fails to get the desired nutriment, and both the child and the mother 
become exhausted in consequence. When this is repeated a few 
times, the child is very apt to refuse to make any attempt at nursing. 
In such cases the use of the nipple-shield (Fig. 8) is often indispens- 
able, until the nipple is sufficiently drawn out and developed for 
the child to get hold of. Preceding each nursing it is well to man- 
ipulate the nipple for a few minutes or to elongate it by the use of 
the breast-pump (Fig. 9), but not using sufficient force to draw the 
milk. 



8o NUTRITION AND GROWTH 

ACUTE AND SUPPURATIVE MASTITIS IN THE MOTHER 
When inflammation of the breast develops with fever, chills, and 
prostration, it is usually the result of an infection through the nipple, 
generally one with visible cracks and fissures. For our purposes the 
different varieties of mastitis need not be considered. Nursing of 
the involved breast should be discontinued, for the sake of both the 
child and the mother; in fact, the pain is often so great that nurs- 
ing is impossible. A supporting bandage should be applied and 
the milk drawn with the breast-pump at the usual nursing times. 
It must be our aim to induce resolution without the formation 
of pus. This is best accomplished by the use of an ice-bag 
which is kept constantly applied to the inflamed, indurated area. 
If there is a tendency to constipation, saline laxatives should be 
used. In fact, the patient will often be benefited not a little by two 
or three watery evacuations daily. With a subsidence of the tem- 
perature and an abatement of the inflammation, nursing may be 
resumed. As soon as the presence of pus is determined, it should 
be removed regardless of its location in the gland. I have seen cases 
of intestinal infection in the infant and of infectious processes in other 
parts of the body that were undoubtedly due to its being allowed to 
nurse on suppurating breasts. 

THE WET-NURSE 

We are called upon to select a wet-nurse under various conditions. 
In a few families, particularly in those who have had disastrous 
feeding experiences, we are asked that no attempts at artificial 
feeding be made, but that a wet-nurse be engaged in advance of the- 
confinement so as to be ready when the time for her service arrives. 
Usually, however, our minds and those of the parents turn to the 
wet-nurse when nutrition by other methods is a failure. It is well 
to remember in this connection that it is not wise to postpone our 
resort to the wet-nurse too long — until every chance for her being 
of assistance has passed. It may take a few days' observation or 
but a single glance at one of these difficult feeding cases for us to 
decide whether a wet-nurse must be secured. Certain it is that in a 
few cases we cannot do without them. I see perhaps two or three 
cases a year, usually in consultation, in which I insist that further 
attempts at artificial feeding be discontinued because of the reduced 
condition of the patient. 

In the selection of a wet-nurse the age during which nursing is 
most successfully carried on is to be remembered. Other things 
being equal, a wet-nurse should n®t be under twenty- two or over 
thirty-five years of age. The peasant women of the continent of 
Europe make the best wet-nurses. A woman should not be selected 
as a wet-nurse without a thorough examination both of herself and 
of her infant. She must be free from skin diseases, tuberculosis, 



THE WET-NURSK 8l 

and syphilis. Whether she is stout or thin, tall or short, amounts to 
little. Neither can we place much reliance on the size of her breasts. 
Although full, firm breasts and prominent nipples are desirable, the 
best indication as to her nursing ability is the condition of her baby. 
For this reason it. is best not to select a woman before her baby is 
four weeks old, for by that time his physical condition will indicate 
with considerable accuracy the kind of food he has been getting. 
The age of the wet-nurse's milk need not correspond with the age of 
the patient for whom she is engaged. As far as age is concerned, a 
breast-milk from four weeks to three months old will answer for any 
infant. 

The results attending the first few days of w^et-nursing are often 
most disappointing. The radical change which takes place in the 
nurse's habits of life, the leaving of her own child to the care of 
others sometimes produces nervous conditions which may have a 
decidedly unfavorable influence upon her milk. So before arriving 
at the conclusion that she will not answer in a given case, she should 
have time to adjust herself to the changed conditions. Many a good 
wet-nurse has been ruined, so far as her usefulness as a milk-producer 
is concerned, by over-indulgence at the table. She has been accus- 
tomed to a very plain diet and some work, which necessarily means 
exercise. Upon assuming her new office she is temporarily the 
most important member of the household, next to the baby, and 
articles of food are supplied to which she is entirely unaccustomed 
and of which she eats plentifully. The result is an attack of indiges- 
tion with fever, the baby is made ill, and the usefulness of the wet- 
nurse in the family ceases. These women usually do best upon a 
plain diet of meat, poultry, fish, vegetables, cereals, and milk. If 
they are accustomed to taking beer, one bottle daily may be per- 
mitted. Coffee may be allowed to the extent of one cup daily, and 
of tea not more than two cups should be allowed. Women of this 
class are almost invariably neglectful of the bowel function, so that 
this must be attended to. One free evacuation should take place 
daily. As a rule, the wet-nurse has been accustomed to work and 
will be more contented and happy when her time is occupied. Being 
out of doors from three to four hours a day is of decided advantage 
to every nursing woman. If she possess sufficient intelligence to 
take the baby for his outings, she should be allowed to do so. For 
the comfort of the family it is wise not to let a wet-nurse know her 
full value. When she feels that she is indispensable, trouble is apt 
to follow from one source or another. It is particularly necessary, 
therefore, that babies that are wet-nursed should be given one 
bottle-feeding daily as soon as they are able to take care of it. The 
wet-nurse will then realize that? she can be dispensed with in case 
of misconduct, or if she leave with an hour's notice the child can be 
given the bottle until another nurse is secured. In the great majority 



82 NUTRITION AND GROWTH 

of my cases it has not been necessary to continue the wet-nursing 
after the children are seven months of age, for by this time they can 
usually be fed on the bottle. Of course, unless her nursing proves 
unsatisfactory, a wet-nurse should not be dismissed at the com- 
mencement of or during the summer. 

SUBSTITUTE BREAST-FEEDING; ARTIFICIAL FEEDING 

A considerable number of the young of the human race are 
deprived of their natural means of nutrition, the milk of the mother. 
For comparatively few is a wet-nurse available. While in proportion 
to the children born more mothers are nursing their infants now than 
formerly, nevertheless every year thousands of infants are brought 
into the world who have to be nourished by other means than human 
milk. The fact that an immense number of deaths occur every 
year among these infants because of defective nutrition speaks for 
itself. 

Nutritional Errors. — Mortality statistics give a very inadequate 
idea as to the part played by nutritional errors in the young, for the 
reason that in many instances such errors are not the direct or perhaps 
the immediate cause of death, and for this reason their influence does 
not appear in mortality statistics. As elsewhere pointed out, and 
dwelt upon at length in this work, in disease of any nature a child's 
resistance is a factor of paramount importance. With defective 
nutrition, resistance is invariably below the normal. Many of the 
infants who die from the intestinal diseases of summer, from grippe, 
from tuberculosis, or from infectious diseases, suffer from defective 
nutrition in different degrees of severity before the immediate cause 
of death appears. 

The Needs of the Patient Paramount. — As the nutrition deals 
directly with questions of life and death, it is not surprising that 
volumes have been written on the subject, but it is surprising that the 
fundamental principles of infants' nutrition are so little understood. 
This is due in part to the fact that writers and teachers of infant- feed- 
ing, in their efforts to be scientific or ultra-scientific, have lost sight 
of the point that there is a patient as well as a pupil to be considered, 
and that not a few teachers with their algebraic or otherwise intricate 
formulas do little but obstruct the progress of rational feeding by 
making a readily comprehended subject impossible to many. Another 
common error is in not distinguishing between children — the rich 
and the poor, the sick and the well. A child with malnutrition, with 
marasmus, or with a temporarily disordered digestion is by no means 
a well baby, and when he is given food suitable only for the well, his 
condition very naturally is not improved. 

Environment. — In feeding an infant, several predominant factors 
must be considered : First, the influences of environment. The infant 
in a children's institution has to be fed differently from one who comes 
to a dispensary for treatment, and both must be fed differently in 



SUBSTITUTE BRE: AST-FEEDING ; ARTIFICIAL FEEDING 83 

summer than in winter. The child of weU-to-do, intelligent parents 
is fed still differently. There are no hard and fast lines in infant- 
feeding other than that there must be an ample supply of such 
nourishment as the child can digest and thrive upon. Cow's milk 
is used as the basis of infants' food, for the reason that it is 
ordinarily readily adapted to the child's digestion and is the most 
available human milk substitute. 

Successful Substitute Feeding. — Successful substitute feeding of 
infants consists, then, in giving something upon which the child can 
live and thrive, and when, in addition, this "something" supplies 
the nutrition which Nature demands, it constitutes scientific infant- 
feeding, whatever the source of the nutriment. Cow's milk is just 
as fully an unnatural food for an infant as is barley or rice gruel or 
the milk of the goat or the ass, and cow's milk only is used, as already 
mentioned, because in a great majority of cases it answers the given 
purpose better than does any other food, in that it furnishes in 
available form the nearest approach to the nutritional elements 
required. From an analysis of many human milks we know what 
should constitute a child's food. Cow's milk, however, differs from 
human milk in important features. 



COW'S MILK 

As cow's milk furnishes the most available basis of nutrition for 
the infant who is to be deprived of the mother's milk, it is necessary, 
in order to secure the best results in its use as an infant food, that 
it contain total solids between 12 and 13 percent, and that the solids 
be represented in the nutritional elements in somewhat the following 
proportions : 

Fat 3.5 to 4 percent 

Sugar 4 to 4.5 " 

Total xjroteid 3 to 4 

Ash 0.7 to 0.9 

Specific gravity 1.028 to 1.033 

In order that there may be a fairly constant strength of the milk, 
herd-milk is to be preferred to the product of one or two cows, as 
the quality of the latter may vary considerably from day to day. 
It has been demonstrated that the best cows for this purpose are 
what is known as "grade cows," that is, not pure bred. Such cows 
thrive better, are more easily kept healthy, and are more uniform in 
the nutritional equivalent of their milk-supply than are high-class 
registered herds of the Alderney or Jersey strain. 

The fat of cow's milk is in the form of a fine emulsion and sepa- 
rates as cream. Its character is affected by the cow's food, being 
softened when some articles are fed and hardened when other kinds 
of food are used. 



84 NUTRITION AND GROWTH 

There are several proteids of cow's milk, of which the most 
important and best known are casein, which forms the curd, and 
lactalbumin, the proportion being about three parts casein to one 
part of lactalbumin. In mixed milk from several cows this propor- 
tion is by no means constant. The sugar of cow's milk is lactose, 
which is less sweet to the taste than cane-sugar or granulated sugar 
or maltose derived from starch. That cow's milk shall contain a 
certain quantity of total solids, and that it shall be of a specific 
gravity within certain limits, is necessary in order that it may 
supply nourishment to the child. Another most important feature 
to be taken into consideration is cleanliness, which naturally brings 
us to a consideration of the bacteriology of milk — a large subject 
which can be but briefly referred to here. Milk fresh from the 
udder contains very few bacteria, particularly if the first two or 
three jets from each teat are discarded. The time for bacterial con- 
tamination is during the milking and while the milk remains in the 
stable. Certain forms of bacteria are harmless, and it is impossible 
to have a milk absolutely free from bacteria. What we need to 
know is how dangerous bacteria get into the milk, and how they 
cause changes that may convert it into a poison of greater or less 
virulence. 

Harmless Bacteria. — The souring of milk is the result of the 
presence of bacteria which produce changes in the sugar of milk 
with the formation of lactic acid. The "turning" of milk during a 
thunder-shower is due to certain changes in the atmosphere that 
aid in the development of the bacteria which convert lactose into 
lactic acid. 

Harmful Bacteria. — Bacteria of decomposition under conditions 
favorable to their growth attack the proteid constituents of the 
milk, producing putrefactive changes with evolution of poisons 
which may be of the greatest virulence. The putrefactive bacteria 
are always present in stables where manure is allowed to collect, and 
where cleanliness is not observed. When we remember what a 
culture-field milk affords to bacteria, and when we see the manner 
and the surroundings in which it is usually drawn, it is not sur- 
prising that it should contain many millions of bacteria to a cubic 
centimeter. They may enter the milk from the dust in the stable — 
a very fruitful source — or they may find entrance from the milker's 
hands or from droppings of fine particles of manure from the belly 
of the cow. These are among the most dangerous forms of bacteria 
found in milk. When bacteria once gain entrance into the milk, 
their growth is most rapid. In corroboration of this, the observa- 
tion of Parsons^ is most interesting and instructive. He writes as 
follows : 

** There is more or less dust floating in the air of houses and 
^Cornell Reading Course, December, 1905. 



SUBSTITUTE breast-feeding; artificial feeding 85 

stables, and this dust is constantly settling. When it falls into 
milk, it carries bacteria with it. If the milk is warm, these bacteria 
multiply very rapidly ; if the milk is cold, they ma}^ develop slowly, 
but they will be ready for rapid growth as soon as the temperature is 
raised. The production and care of good milk depend very much 
on the care taken to prevent dust from getting into it, and the 
maintaining of a low temperature after it is drawn. 

"Last summer, AA^alter E. King, of the State Veterinary College, 
and myself [Parsons], made a number of tests to determine the 
importance of different sources of milk contamination. In most of 
these tests a definite quantity of sterilized milk at 98° F. was exposed 
to some one kind of contamination that we wished to test. The 
milk was then examined, and in that way we could obtain a fairly 
accurate idea of the extent of this particular kind of contamination. 
Some of the experiments and their results are as follows : 

** I. Exposure to Air in the Stable: Two liters (about two quarts) 
of sterilized milk were placed in a sterile pail and exposed seven 
minutes to the stable air in a passageway behind the cows. This 
stable was doubtless cleaner than the average, and the air contained 
less dust than is often found in places where milk is being handled. 
Immediately after this exposure, the milk was 'planted,' and we 
found it to contain 2800 bacteria per cubic centimeter (about fifteen 
drops) ; in other words, between 5,000,000 and 6,000,000 bacteria 
had fallen into the two liters of milk in this short time. 

"2. Pouring of Milk: AVhen milk is poured from one vessel 
into another, a very large surface is exposed to the air, and great 
numbers of bacteria are swallowed up. The following tests illus- 
trate this point : About five liters of milk were poured from one can 
to another eight times in the stable air. It was found, after pouring, 
that this milk contained practically 100 bacteria per cubic centi- 
meter more than it contained before pouring ; in other words, about 
600,000 bacteria had gotten into the milk on account of this ex- 
posure. 

"In another similar experiment, when there was a little more 
dust in the air, the contamination due to pouring eight times was 
two and one-half times greater than in the preceding experiment. 

"3. Contaminated Utensils: ]vluch contamination of milk results 
from putting it into dishes that have been cleaned and then exposed 
where dust can fall into them. In experiments to determine what 
this kind of contamination amounts to, it has been found that when 
little care is taken to protect the dishes, the milk w411 often contain 
several hundred times as many bacteria as when the utensils were 
protected from dust. In order to illustrate this point, two pails 
were carefulty washed and sterilized. One of them was covered 
with sterile cloth to keep dust from falling into it. The other was 
left exposed for only a few minutes to the air of a clean creamery. 



86 



NUTRITION AND GROWTH 



A small quantity of sterile milk was then put into each pail, rinsed 
around, and then examined for bacteria. It was found that the 
milk in the pail which was not protected from dust contained 1600 
more bacteria per cubic centimeter than the milk in the protected 
pail. 

"4. Contamination from the Cow's Udder and Body: Great num- 
bers of bacteria fall into the milk when it is being drawn, because 
the milking-pail is directly under the udder, which is being shaken 
more or less by the milker. This kind of contamination may be 
reduced by cleaning the udder. For example, it was found that 
sterile milk, exposed under the udder as long as it takes to milk a 
cow, while the udder was being shaken about the same as when 
milk is being drawn, contained 19,000 bacteria per cubic centimeter. 




i- 




r?) 






1 



fig. 10. — New. 



Figs. 10, 11. — Milk Pails. 



Fig. II.— Old. 



In this case the udder had been wiped off with a dry cloth in much the 
same way as is done in fairly good dairies. 

" In a similar test the udder was wiped with a damp cloth, when 
the number of bacteria was reduced to 4500 per cubic centimeter. 
In a third experiment the udder was wiped with a cloth dampened 
in a 4 percent carbolic acid solution, when the number of bacteria 
was found to be 3200 per cubic centimeter. In cases where no 
particular care is taken to clean the udder, the bacteria getting into 
the milk from this source may run up into the millions. 

*\5. Importance of Small Openings in Milk Pails: (See Fig. 10.) 
From the experiments above mentioned, it will be seen that it is 
impracticable to clean the udder or free the air from dust so per- 
fectly that no bacteria will fall into the milk. The next question is, 



SUBSTITUTE breast-feeding; artificial feeding 87 

How can we reduce the number of those that will fall in, despite all 
reasonable precautions? The easiest way known is to use a small- 
top milking-pail, thus reducing the size of the opening through which 
dirt can fall in. An experiment to illustrate this point showed that 
milk drawn into an ordinary milking-pail (Fig. 11) contained 1300 
bacteria per cubic centimeter; while that drawn into a pail with 
an opening about one -half as wide, contained only 320 bacteria 
per cubic centimeter. This is exactly proportionate to the number 
of square inches of exposed surface in the two pails. For example, 
a pail having a circular top fourteen inches in diameter has an 
opening of 153.86 square inches; a pail with a twelve-inch top has an 
opening of 11 3.04 square inches ; one with a ten-inch top has an open- 
ing of 79.79 square inches; and a pail with an opening six inches in 
diameter has an exposure of 28.26 square inches. (See Fig. 11.) 

"Milkers should get into the habit of using the small-top pail, 
as it is one of the easiest of all ways of reducing the number of bac- 
teria that fall into the milk. 

*'6. Contamination by Flies: A fly or a bit of hay or straw or a 
piece of sawdust or a small hair may carry enormous numbers of 
bacteria into milk, as is shown by the following experiments: 

"A living fly was introduced into 500 c.c. of sterile milk. The 
milk was shaken one minute, when it was found to contain 42 bac- 
teria per cubic centimeter. After twenty-four hours at room- 
temperature, it contained 765,000 bacteria per cubic centimeter, 
and after twenty-six hours, 5,675,000. 

" 7. Dirt in the Milk: A piece of hay about two inches long was 
placed in 500 c.c. of sterile milk. The milk was shaken one minute, 
when it contained 3025 bacteria per cubic centimeter. After 
twenty-four hours at room- temperature, it contained 3,412,500 
bacteria per cubic centimeter. 

" One piece of sawdust from the stable floor was put into 500 c.c. 
of sterile milk. The milk was shaken one minute and its bacterial 
content was then found to be 4080 per cubic centimeter. After 
twenty-four hours at room-temperature it was 7,000,000 per cubic 
centimeter. 

*' A hair from a cow's flank was put into 500 c.c. of sterile milk. 
After shaking the milk for one minute it contained 52 bacteria per 
cubic centimeter. After twenty-four hours at room-temperature it 
contained 55,000 per cubic centimeter, and after thirty-six hours, 
over 5,000,000 bacteria per cubic centimeter." 

The results of the foregoing observations are given in detail, 
in order to impress upon the reader the necessity of exerting his 
energies to the end that the infants under his care may receive a 
less contaminated milk-supply. 

Market Milk. — The legal standards for pure milk in most instances 
relate only to the chemical composition of the milk. The laws of 



88 NUTRITION AND GROWTH 

most of the States call for 12 percent of total solids, and at least 3 
percent of fat. If the milk contains less than these percentages it is 
considered impure, even if it is just as it was when it left the cow's 
udder. Some cows give milk considerably below this standard. 
The chemical analysis of milk does not show whether it is suitable 
for use as an infant food, this point being decided according to its 
freshness and the care with which it has been handled with reference 
to the exclusion of bacteria and the prevention of their growth. 

The production of clean, safe milk is expensive. It costs at 
least two cents a quart to produce milk, without allowing anything 
for the labor of caring for the cows. The milk must be carried to 
the consumer, which is also expensive. Yet, in New York city, milk 
that possesses the legal requirements retails in the grocery stores, 
during the summer months, at 3^ cents a quart — two quarts for 
seven cents. This milk is known as ** grocery milk," and is a very 
poor food for infants. It is teeming with bacteria, as little care is 
taken in its production. 

The next grade of milk is sold in quart bottles which have been 
filled in the country, packed in cracked ice, and shipped to the city. 
The milk contains many bacteria, but is far better than grocery 
milk. It is retailed to the consumer for about eight cents a quart. 

Certified Milk. — The best grade of milk, and the one which 
should be used in feeding infants whenever possible, is known 
as "certified milk," and is produced under the direction of what 
is known as a "milk commission." The establishing of "milk 
commissions" in different cities throughout the country has been 
the means of securing a much better milk-supply than was form- 
erly possible, and has unquestionably been instrumental in saving 
thousands of lives. To Dr. H. T. Coit, of Newark, N. J., is due the 
credit of organizing the first milk commission. Certified milk must 
conform to certain standards as to its nutritional value and as to the 
number of bacteria per cubic centimeter. These standards are estab- 
lished by a committee of medical men who compose the milk com- 
mission and who have complete control of the dairy and its entire 
output. 

The Milk Commission of the New York County Medical Society 
required a standard of milk not exceeding 30,000 bacteria in a cubic 
centimeter. When a dairyman has shown to the satisfaction of the 
Commission that he can produce a milk up to the required standard, 
he is allowed to attach to his bottles of milk labels furnished by the 
Commission certifying to that fact. Milk thus "certified" is taken 
from the delivery wagons from time to time and subjected to exami- 
nation by their bacteriologist in order to determine whether it 
conforms to the requirements of the Commission. In order to show 
the care and supervision necessary for the production of certified 
milk, the requirements of the Milk Commission of the New York 



SUBSTITUTE breast-feeding; artificial feeding 89 

County Medical Society for the Production of "certified milk" are 
given in full : ^ 

*'The most practicable standard for the estimation of cleanliness 
in the handling and care of milk is its relative freedom from bacteria. 
The Commission has tentatively fixed upon a maximum of 30,000 
germs of all kinds per cubic centimeter of milk, which must not be 
exceeded in order to obtain the indorsement of the Commission. 
This standard must be attained solely by measures directed toward 
scrupulous cleanliness, proper cooling, and prompt delivery. The 
milk certified by the Commission must contain not less than 4 percent 
of butter fat on the average, and must possess all the other charac- 
teristics of pure, w^holesome milk. 

"In order that dealers who incur the expense and take the pre- 
cautions necessary to furnish a truly clean and wholesome milk may 
have some suitable means of bringing these facts before the public, 
the Commission offers them the right to use caps on their milk jars 
stamped with the words : 'Certified by the New York County ^ledical 
Society Milk Commission.' 

"Rules for the Producer. — i. The Barnyard. — The barnyard 
should be free from manure and well drained, so that it may not 
harbor stagnant water. The manure which collects each day should 
not be piled close to the barn, but should be taken several hundred 
feet away. If these rules are observed not only will the barnyard 
be free from objectionable smell, which is always an injury to the 
milk, but the number of flies in summer will be considerabh^ dimin- 
ished. These flies, in themselves, are an element of danger; for they 
are fond of both filth and milk, and are liable to get into the milk 
after having soiled their bodies and legs in recently visited filth, 
thus carrying it into the milk. Flies also irritate cows, and by 
making them nervous reduce the amount of their milk. 

"2. The Stable. — In the stable the principles of cleanliness must 
be strictly obser\^ed. The room in which the cows are milked should 
have no storage loft above it; where this is not feasible, the floor of 
the loft should be tight, to prevent the sifting of dust into the stable 
beneath. The stable should be well ventilated, lighted, and drained, 
and should have tight floors, preferably of cement. They should 
be whitewashed inside at least twice a year, and the air should always 
be fresh and without bad odor. A sufficient number of lanterns 
should be provided to enable the necessary work properly to be done 
during dark hours. There should be an adequate water-supply 
and the necessary wash-basins, soap, and towels. The manure 
should be removed from the stalls twice daily, except when the 
cows are outside in the fields the entire time between the morning and 
afternoon milkings. The manure gutter must be kept in a sanitary 
condition, and all sweeping and cleaning must be finished at least 
^Chapin: "Infant Feeding." 



90 NUTRITION AND GROWTH 

twenty minutes before milking, so that at that time the air ma}^ be 
free from dust. 

"3. Water-supply. — The whole premises used for dairy purposes, 
as well as the barn, must have a supply of water absolutely free from 
any danger of pollution with animal matter, sufficiently abundant 
for all purposes, and easy of access. 

"4. The Cows. — The cows should be examined at least twice a 
year by a -skilled veterinarian. Any animal suspected of being in 
bad health must be promptly removed from the herd and her milk 
rejected. Never add an animal to the herd until it has been tested 
for tuberculosis and it is certain that it is free from disease. Do not 
allow the cows to be excited by hard driving, abuse, loud talking, 
or any unnecessary disturbance. Do not allow any strongly flavored 
food, like garlic, which will affect the flavor of the milk, to be eaten 
by the cows. 

''Groom the entire body of the cow daily. Before each milking 
wipe the udder with a clean, damp cloth, and, when necessary, 
wash it with soap and clean water and wipe it dry with a clean towel. 
Never leave the udder wet, and be sure that the water and towel 
used are clean. If the hair in the region of the udder is long and not 
easily kept clean, it should be clipped. The cows must not be 
allowed to lie down, after being cleaned for milking, until the milking 
is finished. A chain or rope must be stretched under the neck to 
prevent this. 

"All milk from cows sixty days before and ten days after calving 
must be rejected. 

**5. The Milkers. — The milker should be personally clean. He 
should neither have nor come in contact with any contagious disease 
while employed in milking or handling milk. In case of any such 
illness in the person or family of any employee in the dairy, such 
employee must absent himself from the dairy until a physician 
certifies that it is safe for him to return. 

** Before milking, the hands should be thoroughly washed in 
warm water with soap and a nail-brush and well dried with a 
clean towel. On no account should the hands be wet during the 
milking. 

''The milking should be done regularly at the same hour morning 
and evening, and in a quiet, thorough manner. Light-colored 
washable outer garments should be worn during milking. They 
should be clean and dry, and when not in use for this purpose should 
be kept in a clean place protected from dust. Milking-stools must 
be kept clean. Iron stools, painted white, are recommended. 

"6. Helpers Other than Milkers. — All persons engaged in the 
stable and dairy should be reliable and intelligent. Children under 
twelve years should not be allowed in the stable during milking, 
since in their ignorance they may do harm, and from their liability 



SUBSTITUTE breast-feeding; artificial feeding 91 

to contagious diseases they are more apt than older persons to 
transmit them through the milk. 

"7, Small Animals. — Cats and dogs must be excluded from the 
stable during the time of milking. 

"8. The Milk. — The first few streams from each teat should be 
discarded, in order to free the milk-ducts from milk that has re- 
mained in them for some time and in which bacteria are sure to have 
multiplied greatly. If, in any milking, a part of the milk is bloody 
or stringy or unnatural in appearance, the whole quantity of milk 
yielded by that animal must be rejected. If any accident occurs by 
which the milk in a pail becomes dirty, do not try to remove the 
dirt by straining, but reject all the milk and cleanse the pail. The 
milk-pails used should have an opening not exceeding eight inches 
in diameter. 

"Remove the milk of each cow from the stable, immediately 
after it is obtained, to a clean room, and strain it through a sterilized 
strainer. 

"The rapid cooling of milk is a matter of great importance. 
The milk should be cooled to 45° F. within one hour. Aeration of 
pure milk beyond that obtained in milking is unnecessary. 

"All dairy utensils, including bottles-, must be thoroughly 
cleansed and sterilized. This can be done by first thoroughly 
rinsing in warm water, then washing with a brush and soap or other 
alkaline cleansing material and hot water, and thoroughly rinsing. 
After this cleansing, they should be sterilized with boiling water 
or steam, and then kept inverted in a place free from dust. 

"9. The Dairy. — The room or rooms where the bottles, milk- 
pails, strainers, and other utensils are cleaned and sterilized should 
be separated somewhat from the house, or when this is impossible 
have at least a separate entrance, and be used only for dairy purposes, 
so as to lessen the danger of transmitting through the milk contagious 
diseases which may occur in the home. 

"Bottles, after filling, must be closed with sterilized discs and 
capped so as to keep all dirt and dust from the inner surface of the 
neck and mouth of the bottle. 

" 10. Examination of the Milk and Dairy Inspection. — In order 
that the dealers and the Commission may be kept informed of the 
character of the milk, specimens taken at random from the day's 
supply must be sent weekh^ to the Research Laboratory of the 
Health Department, where examinations will be made by experts 
for the Commission, the Health Department having given the use 
of its laboratories for this purpose. 

"The Commission reserves to itself the right to make inspections 
of certified farms at any time and to take specimens of milk for 
examination. It also reser\^es the right to change its standards in 
any reasonable manner upon due notice being given the dealers." 



92 NUTRITION AND GROWTH 

Naturally, milk produced in this way is more expensive than when 
little or no care is used, more help is required, and help of a more 
expensive type. Certified milk, or its equivalent, is sold in New 
York city at prices ranging from twelve to eighteen cents a quart. 

Examination of Cow's Milk. — In cow's milk, as in human milk,, 
a chemical analysis is necessary in order to know accurately the 
nutritional elements. The specific gravity varies from i .029 to i .035. 
Milk is acid in reaction to phenolphthalein, and may be neutral to 
litmus. The Babcock milk-test machine is what is generally em- 
ployed in examining cow's milk in laboratories and institutions. 
The test consists in mixing the milk with strong sulphuric acid which 
dissolves the proteids and liberates the fat, the quantity of which 
is read off from the graduated neck of the bottle used in mixing the 
milk and acid. Only the fat is determined in this way. Knowing 
the fat and the specific gravity, the solids other than fat may readily 
be determined by adding to one-fourth of the specific gravity, read- 
ing to the right of the decimal point, one-fifth of the percentage of 
fat. 

Modified Milk. — At one time it was thought that by changing: 
the percentage composition of cows' milk and altering the reaction, 
it could be made practically identical with human milk, and the 
term "modified milk" was applied to cows' milk so manipulated; 
but a great variety of manipulations of cows' milk has been intro- 
duced, which often differs greatly in the principles involved. Yet to 
products of all these different manipulations the term " modified 
milk" is applied. It may mean any one of a dozen or more different 
products. When cows' milk is diluted with water and given as a food 
to an infant, he is given " modified milk." When sugar, cereal gruel, 
lime water, bicarbonate of sodium, or citrate of sodium is added, it is 
still " modified milk." When a prescription is sent to the laboratory 
calling for definite amounts of fat, sugar, and proteids, the product 
furnished is "modified milk." When a mother is told to use a definite 
amount of cream, milk, sugar, and w^ater, " modified milk" is also 
the outcome. 

As a matter of fact, successful infant feeding consists in what I 
have termed " milk adaptation," that is, modifying the milk to suit 
the case in hand. The routine prescribe r is content to prescribe 
** modified milk," that which was originally supposed to be an imi- 
tation of human milk. The best informed prescriber uses " an 
adapted modified milk," which he decides is indicated. 

The analysis of mixed dairy milk shows it to contain approxi- 
mately : 

4.0 percent fat ; 

4.0 percent sugar; 

3.5 percent total proteid. 



SUBSTITUTE breast-feeding; ARTIFICIAL FEEDING 93 

Human milk contains approximately : 

4.0 percent fat ; 

7.0 percent sugar; 

1.5 percent total proteid. 

The Aim of Milk Modification. — The first thought in the modi- 
fication is grossly to make the chief nutritional elements in the food 
prepared from cow's milk correspond to the nutritional elements in 
the human milk. The proteid must be reduced, the sugar increased, 
and the fat reduced even slightly below that usually found in mother's 
milk, as the child's digestive capacity for cow's-milk fat is less by 
from 15 to 25 percent than it is for human milk. 

The Proteid. — The proteid element in an infant's food is its chief 
nutritional content. This has to be reduced to approximately the 
proportions that exist in human milk, and can be accomplished only 
by dilution. The diluent may be plain water or it may be a cereal 
gruel. The average cow's milk contains, as just mentioned: 

4.0 percent fat ; 

4.0 percent sugar ; 

3.5 percent total proteid. 

If eight ounces of milk is mixed with eight ounces of water, w^e get 
a pint mixture with an approximate nutritional equivalent of : 

2.0 percent fat; 

2.0 percent sugar; 

1.75 percent total proteid. 

If four ounces of milk is mixed with twelve ounces of water we have 
a sixteen-ounce mixture with an approximate nutritional equivalent 
of: 

i.o percent fat; 

1 .0 percent sugar ; 

0.9 percent total proteid. 

If six ounces of milk is mixed with ten ounces of water a sixteen- 
ounce mixture is produced with an approximate nutritional equiva- 
lent of: 

1.5 percent fat; 

1.5 percent sugar; 

1.3 percent total proteid. 

Ey this simple dilution with water it may be seen that the desired 
proteid content of the food may be arrived at. 

The Sugar. — For nourishment for an infant, however, the mixture 
is weak in fat and very weak in sugar. The sugar content is increased 
by the addition of milk-sugar or cane-sugar. It will be remembered 



94 



NUTRITION AND GROWTH 




that with human milk there is a sugar content of 7 percent. The 
combination of full cow's milk and water as above gives a sugar 
content of 2 percent or less, so that sufficient sugar must be added 
to make the increase approximately 7 percent. What is necessary, 
then, is to increase the sugar content 5 percent. A i percent sugar 
and water mixture would contain approximately five grains of sugar 
to the ounce. A 6 percent sugar mixture would contain thirty 
grains to the ounce, and as our dealings are with 
a sixteen-ounce mixture we will require an addi- 
tion of sixteen times thirty grains of sugar of milk, 
or 480 grains, so that if we direct that a pint mix- 
ture contain 6 ounces of a 4, 4, 3.50 milk, 10 ounces 
water, i ounce milk-sugar, there would be an ap- 
proximate nutritional equivalent of : 

1.5 percent fat; 

7.5 percent sugar; 

1.3 percent total proteid. 

Or if it were 4 ounces milk, 12 ounces water, i 
ounce milk-sugar, there would be an approximate 
nutritional equivalent of: 

1 .0 percent fat ; 

7.0 percent sugar; 

0.9 percent total proteid. 

The Fat. — While a child of from two to four 
months might thrive on the above formulas, the 
fat is obviously deficient and needs to be increased. 
This is accomplished by the use of cream. 
Cream of the same age as the milk should be 
used. When this method of feeding is carried 
out, in order to secure a suitable cream, a quart 
bottle of milk from a mixed herd of grade cows 
is allowed to stand at a temperature of 40° or 
50 ° F. for five hours, when a cream which will be 
referred to as "gravity cream" (page iii) will be 
produced of the approximate strength of : 

16.0 percent butter fat; 
3.2 percent sugar; 
3.2 percent total proteid. 

These were the percentages obtained in an analy- 
sis made for me from the Walker-Gordon Laboratory milk, which is 
produced by grade cows and represents an average milk strength as. 
regards the nutritional elements, and may therefore be taken as a 
guide in using gravity cream for infant-feeding. Cream from well- 
fed Jersey cows procured in this way will contain from 20 to 24 per- 




FiG. 12.— The Chapin 
Dipper. 



SUBSTITUTE breast-fkeding; artificiae feeding 95 

cent of fat. One ounce of gravity cream with fifteen ounces of water 
gives a pint mixture with a nutritional equivalent of: 

I .o percent fat ; 

0.2 percent sugar; 

0.2 percent total proteid. 

Two ounces of gravity cream and fourteen ounces of water give an 
approximate nutritional equivalent of : 

2.0 percent fat; 

0.4 percent sugar; 

0.4 percent total proteid. 

We now wish by using gravit}^ cream to raise the fat in the milk 
and sugar-water mixtures given above. In using the cream all 
must be removed and mixed, as the upper layers in the bottle are 
much richer in fat than those nearer the milk. For this skimming 
process the Chapiri dipper (Fig. 12) is employed. Milk which is 
rapidly cooled immediately after being drawn and kept at a tempera- 
ture of 50 ° F. or lower may be skimmed at the end of five hours, when 
all the cream that will rise will have done so. 

Illustrative Food Formulas. 

Gravity cream 1 ounce Approximate Percentage Equivalent. 

Milk 4 ounces Fat 2.0 

Milk-sugar 1 ounce Sugar 7.2 

Water 11 ounces Total proteid. 1.1 

Gravity cream 2 ounces Approximate Percentage Equivalent. 

Milk 4 ounces Fat 3.0 

Milk-sugar 1 ounce Sugar 7-.4 

Water 10 ounces Total proteid 1.3 

In the event of a weak proteid digestion in a young baby, gravity 
cream alone may be used temporarily ; thus 3 ounces cream, i ounce 
milk-sugar, 12 ounces water, i ounce lime-water, which mixture 
gives an approximate nutritional equivalent of: 

3.0 percent fat; 

6.6 percent sugar; 

0.6 percent total proteid. 

Or if a weaker food is desired for a younger infant, we may use 
2 ounces gravity cream, i ounce milk-sugar, 13^ ounces water, 
^ ounce lime-water, which mixture gives an approximate equiva- 
lent of: 

2.0 percent fat; 

6.4 percent sugar; 

0.4 percent total proteid. 

In the event of a good proteid digestion and poor fat digestion, full 
milk alone with sugar and water is to be used ; thus 5^ ounces milk, 



96 NUTRITION AND GROWTH 

lo ounces water, i ounce milk-sugar, ij ounces lime-water, which 
mixture gives an approximate equivalent of: 

1.33 percent fat; 

7.33 percent sugar; 

1. 1 7 percent total proteid. 

Average skimmed milk with the gravity cream removed contains 
about I percent fat, 3.5 percent sugar, and 3 percent proteid. If 
for any reason a particularly weak fat food is required, skimmed 
milk may be used : 5 J ounces skimmed milk, 9 ounces water, i ounce 
milk-sugar, if ounces lime-water, which mixture gives an approxi- 
mate equivalent of : 

0.33 percent fat; 

7.17 percent sugar; 

I. GO percent total proteid. 

If a stronger skimmed milk mixture is required, it may be pre- 
pared as follows : 8 ounces skimmed milk, 8 ounces water, i ounce 
milk-sugar, which mixture gives an approximate nutritional equiva- 
lent of: 

0.50 percent fat; 

7.75 percent sugar; 

1.50 percent total proteid. 

It will thus be seen that with milk, cream, and sugar of milk every 
possible form of food strength may be made. If lime-water is used, 
it simply takes the place of the milk diluent and replaces so much 
water. This method of milk preparation is more accurate than 
when top-milk mixtures are used, but it has the disadvantage of 
requiring two quarts of milk during the entire feeding period, one 
to supply the milk and the other the cream, all of which must be 
removed and mixed before any of it is used in the food. 

The following formulas for the different ages may be found 
useful for well babies: 

From the first to the third day: 

Milk-sugar | ounce 

Boiled water 16 ounces 

I to 1 ounce every two or three hours ; 

which mixture gives an approximate nutritional equivalent of 
3 percent sugar. 

From the third to the tenth day: 

Gravity cream ^ ounce Approximate Percentage Equivalent. 

Milk 3 ounces Fat 1.25 

Milk-sugar 1 ounce Sugar 6.85 

Lime-water h ounce Total proteid 75 

Boiled water to make 16 ounces 

Ten feedings in twenty-four hours ; 1 to 1 1 ounces at each feeding. 



SUBSTITUTE breast-feeding; ARTIFICIAL FEEDING 97 

From the tenth to the twenty-first day: 

Gravity cream l^ ounces Approximate Percentage Equivalent. 

Milk 5 ounces Fat 1.7 

Milk-sugar i^ ounces Sugar 7.0 

Lime-water h ounce Total proteid 0.89 

Water to make 24 ounces 

Nine to ten feedings in twenty-four hours; ij to 2 ounces at each feeding. 

From the third to the sixth week: 

Gravity cream 2^ ounces Approximate Percentage Equivalent. 

Milk 8 ounces Fat 2.25 

Milk-sugar 2 ounces Sugar 7.25 

Lime-water 2 ounces Total proteid 1.13 

Water to make 32 ounces 

Eight to nine feedings in twenty-four hours; 2 to 3 ounces at each feeding. 

From the sixth week to the third month: 

Gravity cream 3 ounces Approximate Percentage Equivalent. 

Milk 9 ounces Fat 2.6 

Milk-sugar 2 ounces Sugar 7.4 

Lime-water 2^ ounces Total proteid 1.3 

Water to make 32 ounces 

Seven to eight feedings in twenty-four hours; 2h to 4 ounces at each feeding. 

From the third to the fifth month: 

Gravity cream 4 ounces Approximate Percentage Equivalent. 

Milk 15 ounces Fat 3.1 

Milk-sugar 2 ounces Sugar 6.8 

Lime-water 4 ounces Total proteid 1.6 

Water to make 40 ounces 

Six to seven feedings in twenty-four hours; 4 to 5 ounces at each feeding. 

From the fifth to the seventh month: 

Gravity cream 5 ounces Approximate Percentage Equivalent. 

Milk 18 ounces Fat 3.6 

Milk-sugar 2 ounces Sugar 6.6 

Lime-water 5 ounces Total proteid 1.9 

Water to make 42 ounces 

Six feedings in twenty-four hours; 5 to 7 ounces at each feeding. 

After the fifth month it is my custom to add from one to three tea- 
spoonfuls of a cereal jelly to each feeding. This may be added to the 
milk mixture when it is made in the morning. Thus, if one teaspoon- 
ful is to be given at each feeding where a child is getting six feedings, 
six teaspoonfuls of the jelly may be added to the entire quantity. 

From the seventh to the ninth month: 

Gravity cream 6 ounces Approximate Percentage Equivalent. 

Milk 23 ounces Fat 3.9 

Milk-sugar 2 ounces Sugar 6.5 

Lime-water 6 ounces Total proteid 2.1 

Water to make 48 ounces 

Five to six feedings in twenty-four hours; 6 to 8 ounces at each feeding. Five 
feedings in twenty-four hours usually answer better at this age. 



98 NUTRITION AND GROWTH 

From the ninth to the twelfth month: 

Gravity cream 7 ounces Approximate Percentage Equiva-lent. 

Milk 32 ounces Fat 4.28 

Lime-water 6 ounces Sugar 7.25 

Milk-sugar 2^ ounces Total prctteicl 2.4 

Water to make 56 ounces 

Five to six feedings in twenty-four hours; 7 to 9 ounces at each feeding. 

Top-milk Feeding. — In using top-milk for infant-feeding the 
milk is allowed to stand in a quart bottle at a temperature of 45° to 
50° F. for the same length of time as when gravity cream is desired — 
five hours — when the quantity needed is removed from the top of 
the bottle with a Chapin dipper (Fig. 12) and diluted as desired 
with water or gruel to which sugar of milk and lime-water are 
added. The milk selected should be the cleanest obtainable from 
grade cows; usually the most expensive is the best. If so-called 
** certified milk" (page 88) is obtainable, it should be used, as this 
warrants a cleaner food than that furnished by the usual market 
milks. 

From a quart bottle of milk on which the cream has risen, dip 
from the top with a Chapin dipper sixteen ounces and mix. From 
average milk this should contain: 

7.0 percent fat; 

3.2 percent sugar; 

3.2 percent total proteid. 

The following top-milk formulas are suggested for the various ages 
noted : 

From the third to the tenth day: 

Milk (top 16 oz.) 3 ounces Approximate Percentage Equivalent. 

Lime-water ^ ounce Fat 1.3 

Milk-sugar i ounce Sugar 6.6 

Boiled water to make 16 ounces Total proteid 0.6 

Ten feedings in twenty-four hours; i to ij ounces at each feeding. 

From the tenth to the twenty-first day: 

Milk (top 16 oz.) 6 ounces Approximate Percentage Equivalent. 

Lime-water i^ ounces Fat 1.75 

Milk-sugar i^ ounces Sugar 6.8 

Water to make 24 ounces Total proteid 0.8 

Nine to ten feedings in twenty-four hours; i J to 2 ounces at each feeding. 

From the third to the sixth week: 

Milk (top 16 oz.) 10 ounces Approximate Percentage Equiv.alent. 

Lime-water 2^ ounces Fat 2.2 

Milk-sugar 2 ounces Sugar 7.0 

Water to make 32 ounces Total proteid . i.o 

Eight to nine feedings in twenty-four hours; 2 to 3 ounces at each feeding. 

From the sixth week to the third month: 

Milk (top 16 oz.) 12 ounces Approximate Percentage Equivalent. 

Milk-sugar 2 ounces Fat 2.6 

Lime-water 3 ounces Sugar 7-2 

Water to make 32 ounces Total proteid .1.2 

Seven to eight feedings in twenty-four hours; 2^ to 4 ounces at each feeding. 



substitute: breast-feeding; artificial feeding 99 

Fro7n the third to the fifth month: 
After this age two bottles of milk are required, i6 ounces being 
taken from the top of each bottle and mixed. At this time a cereal 
jelly is usually added to the food (page 97). 

Milk (top 16 oz.) 18 ounces Approximate Percentage Equivalent. 

Milk-sugar 2 ounces Fat 3.15 

Lime-water 4 ounces Sugar 6.4 

Water to make 40 ounces Total proteid 1.4 

Six feedings in twenty-four hours; 4 to 5 ounces at each feeding. 

From the fifth to the seventh month: 

Milk (top 16 oz.) 21 ounces Approximate Percentage Equivalent. 

Milk-sugar 2 ounces Fat 3.50 

Lime-water 5 ounces Sugar 6.4 

Water to make 42 ounces Total proteid 1.6 

Six feedings in twenty-four hours; 5 to 7 ounces at each feeding. 

From the seventh to the ninth month: 

Milk (top 16 oz.) 27 ounces Approximate Percentage Equh'alent. 

Milk-sugar 2 J ounces Fat 3.9 

Lime-water 6 ounces Sugar 7.0 

Water to make 48 ounces Total proteid 1.8 

Five to six feedings in twenty-four hours; 6 to 8 ounces at each feeding. 

From the ninth to the twelfth month: 

Milk (top 16 oz.) 35 ounces Approxim.ate Percentage Equivalent. 

Milk-sugar 2^ ounces Fat 4.3 

Lime-water 6 ounces Sugar 6.5 

Water to make 56 ounces Total proteid 2.0 

Five to six feedings in twenty-four hours; 7 to 9 ounces at each feeding. 

After the twelfth month, plain cow's milk may be given with the 
cereal jelly in addition to the other articles of diet suggested for 
a child one year old. (See page 134.) 

It will be noticed that considerable latitude is allowed as to 
the amount of food which may be given at each feeding. This is 
because of the difference in the capacity of individual children. 
It will be observed that the total quantity of food prepared is several 
ounces more than it is supposed the child will take in twenty-four 
hours. This extra amount often serves a most useful purpose when 
a bottle is broken or the food is otherwise lost. The average well 
child will require about thirty ounces of a suitably adapted food at 
the third month. He will need about thirty-six ounces at the sixth 
month and forty to forty-five ounces at the ninth to the twelfth 
month. 

Night Feedings. — After the third month the midnight feeding 
should be discontinued. Six feedings will be sufficient, the first 
at 6 A. M. and the last at 10.30 or 11 p. m. 

Between 11 p. m. and 6 A. m. the child should sleep. Babies 
are easily broken from the night bottle by substituting a bottle of 



lOO NUTRITION AND GROWTH 

boiled water or a milk mixture greatly diluted with water. The 
child soon discovers that this is not worth waking for. As a result 
of a full night's rest the digestive organs are better able to do their 
work, the appetite is increased, and a larger amount of food may be 
given at each feeding. 

Changes Needed for Special Symptoms. — ^When the milk does 
not agree, the cause must be discovered. The food as a whole 
may be too strong, when there will be indigestion and colic, and 
possibly diarrhea and vomiting. If the food contains too much fat, 
there will be looseness of the bowels and colicky stools, with con- 
siderable straining, and there is apt to be regurgitation also. The 
sugar is rarely a cause of trouble, indications of excess being the 
eructation of gas and a regurgitation of sour, watery material. It is 
comparatively rare, however, for the fat and sugar to cause any 
disturbance if they are given with any degree of intelligence ; but 
the casein, the curd-forming element in cow's milk, often gives us 
no end of trouble. Many infants, as previously stated, are able to 
digest only a very weak cow's-milk casein; consequently, at the 
beginning of cow's-milk feeding, when, as is often the case, too 
much milk is used — too strong a food given — the result is always 
disastrous. This, with too frequent feedings and night feedings, 
comprise the chief errors made in cow's-milk feeding — in fact, they 
are the cause of more bottle-feeding failures than all other factors 
combined. 

The Quality of Milk Variable. — It is not claimed that the nutri- 
tional value as indicated by the percentage equivalents in either of 
the above series is absolutely correct. Milks necessarily differ in com- 
position. Only mixed dairy milk is referred to, the product of several 
grade cows. The feeding of the cows and their care also influence the 
quality of the milk. The percentages indicated give approximately 
the nutritional value and are sufficiently accurate for purposes of 
supplying satisfactory nutrition to well babies of the various ages, as I 
have abundantly proved to my own satisfaction. The fats will not be 
found too low for proper nutrition in any of the formulas given. 
They may be too high for proper digestion and require adjustment. 
The proteids as given are sufficient for nutrition if they are assimi- 
lated. They also may require reduction to meet special conditions 
which are referred to under Milk Adaptation (page 105). The adjust- 
ment of the food to the individual, constitutes what I have termed 
"Milk Adaptation," and suggestions for making the food fit the 
child's digestive capacity will be found under that caption. 

Laboratory Feeding. — ^To Rotch, of Boston, we are indebted for 
the establishment of the practice of thinking in percentages in the 
feeding of infants and for the establishment of milk laboratories 
which mark an epoch in the feeding of infants. Haphazard methods 



SUBSTITUTK BRKAST-FEBDTNG ; ARTIFICIAL FEEDING 



lOI 



of feeding have been superseded by methods which rest upon a 
scientific basis. The change for the better has been slow but effec- 
tual, so that all who now teach or practise pediatrics successfully 
must think in percentages and feed accordingly. The advantages 
of using the milk of a properly conducted laboratory are accuracy 
in the nutritional content in the food furnished and cleanliness. 
It also lightens the household duties, the milk being delivered every 
morning ready for use. The physician sends the prescription to the 
laboratory on such a prescription blank as that shown below : 



I^. 



Fat 

Milk-sugar 
Proteids . . 
Lime-water 
Diluent . . . 



Percent. 



Number of 
feedings - 



Amount of 
each feeding 



In Ot. Jar- 
Heat to — 



Ordered for- 



Date 



Signature 



-M.D. 



The milk thus is delivered in quart bottles or in as many nursing 
bottles as there are feedings in twenty-four hours, each bottle con- 
taining the number of ounces called for. 

A further advantage possessed by the laboratory is that in very 
difficult cases of proteid feeding a finer adjustment is possible than 
is the case with home-made preparations, a very valuable aid in the 
feeding of such cases. A splitting up of the proteid by using whey 
proteid is here more accurately accomplished than is possible in the 
home. Unfortunately, the product of milk laboratories, on account 
of the expense of equipment and maintenance, together with the 
expense of producing a high-grade milk at the farm, is rendered so 
expensive to the consumer that it is available to comparatively few. 

A Convenient Means for Home Modification. — A measuring 
glass has recently been placed on the market, known as the 
Deming percentage milk modifier (Fig. 13). The device is a pint 
graduate provided with a column of figures in red representing 
percentages of proteid, and several other columns representing 
percentages of fat. The fat percentages in one column are to 
be obtained by using whole milk, in another 7 percent milk, in 



I02 



NUTRITION AND GROWTH 



another lo percent, etc. At the head of each column are direc- 
tions showing how such a milk may be obtained from a quart bottle 
of milk. The figures representing proteid percentages are so placed 
on the glass that when milk is poured into the graduate up to the 
level of any set of figures and diluent added up to the sixteen-ounce 
mark, the resulting mixture will contain a percentage of proteid 
corresponding to the red figure at the first level and a percentage 
of fat corresponding to the figures at that level in the column which 
represents the kind of milk used. For example, if whole milk is 
poured in up to the red (proteid) mark 2 and diluent added to sixteen 
ounces, the fat percentage will be 2.5, which is the figure at the same 
level as the proteid percentage, and under the whole-milk column. 
Or if 7 percent milk is used, 4.4 percent, and if 10 percent, 6.2 per- 
cent, etc. 

The Feeding of Dispensary Patients. — The feeding of cow's 
milk according to one or more of the above methods is the 
best means of furnishing infant nutrition. The laboratory, the 
milk and cream, or the top-milk methods all pediatrists are 
agreed have proved the best means of applying substitute feed- 
ing. That a great majority of infants may be fed in this way, 
if they are properly handled by a suitable adjustment, there is not 
the slightest doubt, but where there is a majority, there is also a 

minority, and a goodly portion of 
this minority who reside in large 
cities ai\d the suburbs of large cities 
fall into the hands of the pediatrist 
either in hospital, in out-patient, or 
in private work. Economic ques- 
tions oftentimes govern the selec- 
tion of the food. Physicians who 
have an invariable system of feed- 
ing must of necessity have but one 
type of patients to deal with. 

As loud as we may be in our 
advocacy of the ennobling principles 
of democracy, we cannot treat alike, 
as regards their feeding, all well chil- 
dren even in private practice. The 
child of a stupid mother cannot be 
fed as well or in the same way as 
the child of a reasonably intelligent 
mxOther in the same station of life. 
An infant of a very poor mother, 
whether she is dull or intelligent, 
cannot be fed to the infant's best advantage, for the reason — a very 
simple but effectual one — that the mother cannot afford cow's milk. 




JllREQ CO UPP/M 



Fig. 13.— Deming's Milk Modifier. 



SUBSTITUTE breast-feeding; ARTIFICIAL FEEDING 103 

Among the out-patient class in New York city, the expensive milk 
is therefore entirely out of the question. I have treated manv infants 
whose parents could not expend eight cents daily for a quart of milk. 

The Patient's Limitations and How to Meet Them. — The Straus 
laboratories, which supply pasteurized milk to the poor of New 
York city, excellent as they are, are available to comparatively 
few. Milk and cream conihinations are impossible oftentimes be- 
cause of expense or because of inability to appreciate and carr\^ 
out the details required for their proper use, so that in the out- 
patient poor class we have to feed either by top-milk methods or 
by the simple dilution of full milk with water and sugar or with a 
cereal gruel and sugar, while for the very poor, those who cannot 
afford cow's milk and ice, we are forced to use condensed milk. 
The top -milk method is available to but comparatively few of 
these mothers, even though the directions are carefully explained 
and printed instructions used. The use of top milks with many, 
while the method is very simple, is not readily understood, and it 
has usually been unsatisfactory. The dipper, a useful portion of the 
equipment, makes an extra utensil to be kept clean. Women who 
do all their own housework, take care of their own children, and 
perhaps take in outside work have but little time for attention to 
the details of infant-feeding. The easiest way, naturally, has for 
them many attractions. Among these patients my best success 
has been in the use of jiill milk. They know how to shake the bottle 
and measure out the milk and mix it with water or barley-water, 
in the amount to be fed to the baby. Further than this, their 
comprehension frequently does not extend, and, again, this is very 
easily done. 

As will readily be perceived, the feeding of diluted full milk 
gives a food poor in fat. This we endeavor to make up by using 
three times a day one-half teaspoonful or one teaspoonful of pure 
cod-liver oil, for which there is no charge at the dispensary. 

The following formulas and instructions for bottle-feeding are 
taken from the Rules for the Care of Infants and Young Children 
which are used in my service at the out-patient department of the 
Babies' Hospital, and give the simplest and easiest means of bottle- 
feeding. 

''Bottle-feeding: The bottle should be thoroughly cleansed 
with borax and hot water (one tablespoonful of borax to a pint of 
water) and boiled before using. The nipple should be turned inside 
out, scrubbed with a brush, using hot borax water. The brush 
should be used for no other purpose. The bottle and nipple 
should rest in plain boiled water until wanted. Never use grocery 
milk. Use only bottled milk w^hich is delivered every morning. 
From May ist to October ist the milk should be boiled five minutes 
immediately after receiving. Children of the same age varv^ greatly 
as to the strength and amount of food required. A mixture, when 



I04 NUTRITION AND GROWTH 

prepared, should be put in a covered glass fruit-jar and kept on the 
ice. For the average baby the following mixtures will be found 
useful : 

" For a child under six weeks of age: Nine ounces of milk, twenty- 
seven ounces of barley-water, four teaspoonfuls of granulated 
sugar. Feed from two to three ounces at two and one-quarter- 
hour intervals, nine feedings in twenty-four hours. 

'^ Sixth to the twelfth week: Twelve ounces milk, twenty-four 
ounces barley-water, five teaspoonfuls sugar. Feed from three 
to four ounces at each feeding. 

'* Third to the sixth month: Eighteen ounces of milk, thirty 
ounces of barley-water, six teaspoonfuls of sugar. Feed four to six 
ounces at three-hour intervals, seven. feedings in twenty-four hours. 

*' Sixth to the ninth month: Twenty-four ounces milk, twenty- 
four ounces barley-water, six teaspoonfuls granulated sugar. Feed 
six to eight ounces at three-hour intervals, six feedings in twenty- 
four hours. 

''Ninth to twelfth month: Thirty-eight ounces milk, twelve 
ounces barley-water, six teaspoonfuls of granulated sugar. Feed seven 
to nine ounces at three and one-half hour intervals, five feedings 
in twenty-four hours. 

"Condensed Milk: When the mother cannot afford to buy 
bottled milk from the wagon, when she has no ice-chest or cannot 
afford to buy ice, she should not attempt cow's-milk feeding, but 
may use canned condensed milk as a substitute during the hot months 
only. The can, when opened, should be kept in the coolest place 
in the apartment, carefully wrapped in clean white paper or in a 
clean towel. The feeding hours are the same as for fresh cow's 
milk. 

** Under three months of age: Condensed milk one-half to one 
teaspoonful ; barley-water, two to four ounces. 

" Third to sixth month: Condensed milk, one to two teaspoonfuls ; 
barley-water, four to six ounces. 

"Sixth to ninth month: Condensed milk, two to three teaspoon- 
fuls ; barley-water, six to eight ounces. 

"Ninth to twelfth month: Condensed milk, three teaspoonfuls; 
barley-water, eight to nine ounces." 

A cereal water is used as a diluent in all of these cases, as it 
increases the nutritional value of the food. One-half ounce barley 
flour to a pint of water gives a nutritional equivalent of: 

0.07 percent fat; 

0.3 percent total proteid; 

2.0 percent carbohydrate. 

Changes Needed in Hot Weather. — It will be seen that the 
foregoing whole-milk formulas are poor in fat, as previously stated, 
but during the hot months they contain as much fat as the aver- 
age tenement child can safely digest without danger of producing 
diarrhea. During the cooler months of the year the child is given 



SUBSTITUTE breast-feeding; artificial feeding 105 

pure cod-liver oil from the dispensary in order to make up for 
the deficient fat content of the food. During the eight months 
from October ist to June ist the child is fed in this way. About 
June ist the conditions of the family are investigated as to their 
ability to care for the milk during the hot weather. If they have 
ice-boxes and can afford ice they are instructed to continue with the 
milk, but instead of giving it raw, as previously, they are told to 
boil it three minutes. When they cannot supply sufiicient ice to 
care for the milk, they are put into the condensed-milk class. A 
fairly satisfactory infant milk may be obtained in New York city 
for eight cents a quart. There are parents in New York, however, 
who cannot afford even this daily expenditure for the infant's milk, 
or who claim that they cannot, which amounts to the same thing, 
as far as the infant is concerned. The infant has to be fed. A 
ten-cent can of condensed milk will last an infant three days, and 
it will keep safely for use for that length of time after opening. It is 
always given in a cereal water diluent in order to increase its nutritive 
value, and pure cod-liver oil furnished by the dispensary is given 
eight months in the year to increase the daily amount of fat. This, 
of course, is anything but an ideal means of infant-feeding. Many 
children thrive on it, however, but they almost invariably show some 
signs of malnutrition, and offer less resistance to illness of every 
nature. In spite of these drawbacks it is the best food for a con- 
siderable number of children during the summer months under 
existing conditions in New York city. 

Adapted Milk. — In adapting milk for infant-feeding the milk 
is not only "modified" (page 92), by which process the nutritional 
elements are changed in their proportions so as to make them con- 
form as nearly as possible to mother's milk, but more is required 
— the food must be adapted to the child's digestive capacity. 

If the modification of milk, as we formerly understood, constituted 
all that was required in infant-feeding, the artificial feeding of infants 
would be a comparatively simple matter. Some infants will take read- 
ily any reasonable modification which by experience has been found 
suitable for children of their age. In others, which includes the 
majority, the child fed on cow's milk has to be fed according to his 
digestive capabilities. Every feeding case must be studied from 
its own individual standpoint. How best to nourish the individual 
patient can be learned only by a study of the patient himself. No 
process of manipulation by the addition of chemicals or gruels can 
convert cow's milk into human milk. There are various means 
available, however, sufficient to overcome the existing differences, 
thereby making cow's milk a suitable food even for those who at 
first show signs of marked intolerance of it. The strength and 
the feeding intervals required for the different ages in average well 
children are found in the chapters on Modified Milk, page 92. 



I06 NUTRITION AND GROWTH 

Symptomatic Adaptation. — If the child is getting a suitable food 
strength at proper intervals and the food causes illness, the difficulty 
may rest either with the food as a whole, it being beyond his digestive 
capacity, or there may be an incapacity for one or more of its nutri- 
tional elements. If the food as a whole is too strong, there is very apt 
to be vomiting, which may become habitual, or there may be colic or 
constipation or diarrhea. If the food as a whole is too weak, it will 
be evidenced by hunger, a failure to gain in weight, and usually by con- 
stipation. If sugar is given in excess — a comparatively rare cause of 
trouble, if not more than 7 percent of milk-sugar is given — it will be in- 
dicated by the regurgitation of sour, watery material. A sour odor to 
the patient's breath and to his clothing indicates sugar excess. There 
may not be pronounced vomiting in such a case, but the repeated 
regurgitation when the patient is awake is sufficient to deprive him 
of a goodly amount of his daily food, or the digestion of both fat 
and proteid may be markedly interfered with, and the whole digestion 
deranged as a result of what was primarily a sugar incapacity or 
sugar excess. When sugar is at fault, the indigestion may readily 
be corrected by washing out the stomach for a few days (page 191) 
and by reducing the sugar content of the food one-half. Later, 
after the condition is relieved, the sugar may gradually be increased 
to the normal percentage of seven. A child may be getting but a 
2 percent cow's-milk-fat mixture and yet suffer from fat indigestion. 
Excessive fat or fat incapacity also gives rise to vomiting and re- 
gurgitation in which particles of fat may often be seen. Fat may 
cause also frequent green undigested stools, the passage of which is 
associated with marked tenesmus. Fat-diarrhea is often the out- 
come of fat-indigestion. Cow's-milk fat was not intended for babies, 
and when it disagrees we cannot change its character — rour only 
method of adaptation is to reduce the amount given, the same as 
with the sugar. 

Casein. — The casein in cow's milk is its important nutritional 
factor, and in adapting cows' milk to a child's digestive capacity it is 
oftentimes a most difficult factor to deal with. Temporarily it may 
be reduced with safety to a percentage considerably below that of 
cow's milk-^to 0.25 percent, for instance^but it must be remembered 
that the patient cannot thrive or even long exist without this proteid 
element in the diet, so that a reduction will always be followed 
by malnutrition. It is necessary, then, to give proteid, and suc- 
cessful infant-feeding means that we must change it through adap- 
tation to the child's digestive capacity, and this, fortunately, is often- 
times possible. 

The Use of Alkalies and Antacids. — The casein of human milk 
when it enters the infant's stomach divides into small iiocculent 
masses. Cow's milk entering the infant's stomach, without an 
addition of an alkali or other influencing medium, is precipitated 



SUBSTITUTE breast-feeding; artificial feeding 107 

by the pepsin in the stomach and forms a heavy curd, which consists 
of paracasein, at which the child's stomach oftentimes rebels, as it 
fails of digestion or assimilation. The adaptation of the casein of 
cow's milk to the child's digestive capacity so as to maintain suitable 
nutrition, is a central point around which the whole subject of infant- 
feeding revolves. It will be noted in the formulas for cow's-milk 
feeding for different ages that lime-water is used as a diluent. 
This is used not simply as a diluent of cow's milk nor to render the 
milk alkaline, as has frequently been stated ; it is used to prevent the 
coagulation of the casein and the resulting formation of tough curds 
of paracasein. Simple dilution with water may make a smaller 
curd, but it does not produce the peculiar flocculent character 
peculiar to human milk that follows the addition of alkalies and 
antacids to cow's milk. In the presence of an alkali the casein does 
not combine with the acid in the stomach, consequently the resulting 
acid coagulation does not take place, hence alkalies and antacids are 
added to cow's milk. 

Recently, Poynton, of London, advocated the use of citrate of 
soda with a view of preventing the solid coagulation of the casein. 
It is claimed that by using citrate of soda, one grain to the ounce, 
sodium paracasein is produced, which is a fluid. Citric acid is 
liberated and unites with the calcium, forming the citrate of calcium, 
which is absorbed. 

Signs of indigestion of the casein in the milk are usually pain 
and discomfort. There are usualh^ acute attacks of colic. There 
may be constipation or diarrhea alternating with constipation, 
associated with the passage of many hard curds in the stools, the 
patient losing steadily in weight. In such instances the best means 
of adaptation consists in reducing the amount of proteid to a total 
of I percent by dilution with water, and the addition of sufficient 
alkalies, such as lime-water, bicarbonate of soda, or citrate of soda, 
to form a curd more readily attacked by the digestive juices. 

Whey -fee ding. — Whey mixtures may be of temporary use in these 
cases. In whey the casein is largely removed — about 0.3 percent 
remaining. Analyses of whey show a nutritional equivalent of about : 

0.5 percent fat; 
0.9 percent lactalbumin; 
0.3 percent casein; 
4.5 percent sugar. 

As whey is ordinarily made, it is impossible to obtain a lower per- 
centage of casein than 0.25. The amount of casein will often- 
times reach 0.5 percent unless it is heated and strained a second 
time. The deficiency in fat may be overcome by adding gravity 
cream (page iii) of the same age as the milk from which the whey 
is obtained, in the proportion of one or two ounces to a pint 



io8 



NUTRITION AND GROWTH 



of whey. This, of course, carries with it a very small amount of 
casein, which may make a total beyond the child's digestive capac- 
ity. Ivow proteid must be given only during acute illness or in those 
digestively ill, and should be a diet for temporary purposes until 
the child is able to care for a more suitable nourishment. My best 
results with the whey-proteid feeding have been in my laboratory 
cases. During the past winter I fed nineteen infants in this way on 
the Walker-Gordon milk, the casein being given at a minimum at 
first — 0.3 percent with 0.9 percent lactalbumin. Later it was gradu- 
ally increased as the child showed that he could assimilate it. 

Adaptation by the Use of Cereal Gruels. — It is claimed by many 
excellent observers that the use of cereal gruels causes a mechanical 
division of the casein, and it is thus more readily acted upon by 
the digestive juices. While I use gruels as milk diluents largely, 
and frequently as milk substitutes, I have yet to be convinced that 
in difficult feeding cases they possess any great value in the adapta- 
tion of casein to the child's digestive capacity. They are valuable 
adjuncts to the diet in cases in which weak-milk foods must be given, 
but I do not recall a case, nor can I find one among my records, 
where I thought the use of a stronger casein possible because of the 
cereal water diluent. Repeated trials with gruels, in delicate or in 
marasmic infants, who afford the crucial tests in any milk adaptation, 
have never enabled me to give a stronger milk proteid because of 
their presence. Having fed gruels as diluents in a large number 
of cases for years, I have had abundant opportunity to see enormous 
curds vomited and passed by the rectum by children on a milk and 
gruel diet in spite of test-tube demonstrations of the minute division 
of the curd when the milk was treated with gruels. In making these 
test-tube demonstrations the process of curdling which takes place 
in the stomach is followed. The advantage of a cereal diluent lies in 
the fact that a greater amount of food is given. 

The following figures will give an idea of the increase in proteids 
and carbohydrates occasioned by the use of gruels made from Cereo 
Go's, barley and oat gruel flours (i oz. or 4 level tablespoonfuls to 
the quart of gruel). The amount of proteids in these flours is higher 
than in the other flours on the market. 



Proportion of Milk 
in Mixture 

one-eighth 

one-quarter 

three-eighths 

one-half 

five-eighths 



PROTEIDS 

Water Diluent 
0.40 percent 
0.80 percent 
1.20 percent 
1 .60 percent 
2.00 percent 



CARBOHYDRATES 



Gruel DDuent 
0.82 percent 
1. 16 percent 
1.50 percent 
1.80 percent 



Water Diluent 

0.60 percent 
1.20 percent 
1.80 percent 
2.50 percent 



2.02 percent 3.00 percent 



Gruel Diluent 
2.7 percent 
3.0 percent 

3.6 percent 

3.7 percent 
4.0 percent 



In adding sugar to mixtures made with these gruel diluents, use 
but about one-half as much as when water diluent is employed. 



SUBSTITUTE breast-feeding; artificial feeding 109 

Adaptation through Peptonization. — When a child has a casein 
incapacity to such a degree that he is not able to take cow's milk 
when properly diluted and given at suitable intervals, the peptoniza- 
tion of milk (page 119) may aid us, although I have frequently been 
sorely disappointed in its use. Theoretically, peptonization — the 
predigestion of the food — should be a solution of many digestive 
problems. Its efficiency in actual use can be learned from mortality 
statistics of children undfer two years of age in large cities, an immense 
proportion of the deaths being due to nutritional errors either primar- 
ily or secondarily. Not every infant, of course, is given peptonized 
milk; but if it possessed the value claimed for it by some of its 
advocates, the demand would be such as to compel its universal 
use and difficult feeding cases would be no more. 

Perhaps I treat five or six cases of casein indigestion a year in 
which peptonization is unquestionably valuable. In using pep- 
tonized milk the proteid strength should be reduced to i percent — 
the lowest point compatible with safety. The amount and intervals 
of feeding should correspond with those suggested for the age of 
the patient. I have found the following method the best: Fifteen 
minutes before nursing the bottle is removed from the ice and from 
one-eighth to one-fourth of a tube (Fairchild's peptonizing tube), 
depending upon the amount of milk in the bottle, is added. The 
bottle is then placed in water sufficiently heated, 110° to 120° F., 
to make it the right temperature for a child at the end of ten minutes. 
The degree of the temperature of the water must of necessity vary 
according to the temperature in the bottle and the amount to be 
heated. 

Malt -soup Feeding. — The use of Loefflund's malt-soup extract 
(a preparation of malt and potassium carbonate), Kellar's formulas, 
offers a most satisfactory method of making cow's milk casein assim- 
ilable. It is not well borne in vomiting cases nor in which there is a 
tendency to looseness of the bowels. When either of these condi- 
tions exist skimmed milk may be temporarily substituted. 

In following this method of feeding the milk strength considered 
suitable for the condition and age of the child may be used. Lime- 
water is not employed because of the presence of carbonate of potash 
in the malt. The malt and the flour, a considerable portion of the 
latter having been dextrinized, take the place of milk or cane-sugar 
in the food mixture. 

Its chief use is in malnutrition cases, in slow-growing infants, 
who though not actually ill, fail to show a satisfactory grow1:h on any 
food given. Time and again I have seen these children show surpris- 
ing increase in weight without change in the milk strength when the 
malt-soup with its wheat flour accompaniment was used. In bottle- 
fed infants who suffer from colic and marked constipation due to 
casein incapacity it has a considerable field of usefulness. 



no NUTRITION AND GROWTH 

Malt-soup extract is not to be used in the strength as indicated 
on the bottle, as the amount is entirely too high. I have found the 
following method the most satisfactory: For a thirty-ounce mixture, 
dissolve one ounce of the malt extract in the amount of water used. 
Mix and blend from one to two ounces of flour by measure with the 
milk, cream, or top- milk required. If there is abdominal distention 
and flatulence or other evidences of carbohydrate incapacity, the 
amount of flour should be reduced perhaps one-half. This is to be 
strained and added to the solution of malt and water. It should 
then be placed over a slow fire and " simmered" for thirty minutes, 
with constant stirring. 

In the event of constipation continuing, the amount of malt used 
may be doubled. Excess of malt, however, may produce vomiting, 
so that an increase should be made with caution. 

The Calorimetric Standard.^ — The calorimetric standard in its 
relation to infant feeding was not included in my first edition be- 
cause I desired this to be a practical work without fanciful theories. 
Numerous writers claim that the use of the caloric standard has been 
of value to them, and its omission from the first edition has been 
noticed by different reviewers. 

In brief, the calorimetric standard is based upon the amount of 
energy indicated in calories for each pound of body weight. A calorie 
is the amount of heat required to raise the temperature of one liter 
of water I °C. 

Heubner, of Berlin, several years ago began the employment of 
calorimetric principles in infant feeding. His original observations 
were made on healthy breast-fed infants, weighing them before and 
after each feeding. His observations showed that under six months, 
one hundred calories were required daily for every kilogram of body 
weight. After the sixth month, the calories required gradually les- 
sened, so that at the completion of one year about eighty-five calories 
to each kilogram of body weight appeared to be necessary. 

Lamb ^ has reduced Heubner's figures to pounds. He gives the 
calorimetric requirements as forty -five calories daily per pound of 
body weight during the first three months of life. During the next 
three months from forty to forty-five calories daily per pound, de- 
creasing gradually during the next six months, so that at the twelfth 
month from thirty-two to thirty-five calories daily per pound of 
body weight would be necessary. 

Heubner's observations upon which the standard is based as men- 
tioned above was made on thriving breast babies. In order to judge 
of its practical value in artificial feeding the histories of thirty-three 
bottle-fed infants were selected at random from my files for investi- 
gation. It was found that every child was getting more food in 
caloric value than the standard called for. All but two required 
^Archives of Pediatrics, June, 1908. 



CRKAM III 

food in caloric value exceeding loo, as set by the standard. In thirty- 
one the daily consumption of these splendidly thriving infants, all 
of which continued to do well, was from 140 to 360 calories in excess 
of the Heubner standard. But thirty-three histories were investi- 
gated. 

I am confident that I have hundreds of records showing the same 
result. The calorimetric standard is to me a means of no utility in 
infant feeding. It might aid as a check to excessive feeding in very 
young and delicate infants. Infants that I see, and they differ not 
at all from the average infants in this country, catmot be fed by it to 
the infant's best advantage, and for this reason it was not referred 
to in the first edition and its use is not advised in this. 

CREAM 

Market creams are known as "gravity cream" and "centrifugal 
cream." 

Gravity Cream. — Gravity cream is obtained by allowing the milk 
to stand for a certain length of time and then removing the cream. 
When milk, as soon as it is drawn, is placed in a quart milk-bottle or 
fruit-jar and kept at a temperature of between 40° and 50° F., most of 
the fat will have risen at the end of five hours. When the cream is 
carefully removed at the end of this time, from 0.3 to 0.8 percent of 
fat will remain in the milk. The fat content of gravity cream is 
subject to considerable variation, depending, of course, upon the 
richness of the milk and the manner in which it is treated, particularly 
as relates to rapid cooling. In the cream from well-kept grade cows 
the fat will average about 16 percent. In cream from well-fed 
Aldemey or Jersey herds it may be as high as 20 percent, or higher. 
In cream from cows indifferently fed, in those who subsist entirely 
upon poor pasturage, the fat may be as low as 10 or 12 percent. For 
infant-feeding, gravit}^ cream from the milk of grade cows is preferred. 
In using cream for infant-feeding all the cream to the milk line should 
be removed, as the upper layers are much richer in fat than that 
adjoining the milk. Further, when cream is mixed with milk both 
must be of the same age, as the addition of older bacteria-laden 
cream to fresh milk will surely result in grave digestive disorders. 

Centrifugal Cream. — Centrifugal cream is that which is removed 
by an apparatus known as a separator, w^hich consists of a circular 
bowl for holding the milk so arranged as to make from 3000 to 5000 
revolutions a minute. This results in a rapid separation of the 
lighter fat from the milk. The fat collects near the center of the 
bowl and is removed by a device arranged for this purpose. The 
skimmed milk flows outward from another portion of the bowl by a 
similar device. Centrifugal cream is more difficult of digestion than 
gravity cream in that the natural emulsion in w^hich the fat is held 
in the milk is destroyed by the process of centrifuging. Centrifugal 



112 NUTRITION AND GROWTH 

cream may vary greatly in its fat content, depending upon the 
rapidity of operation of the separator. According to Babcock and 
Russell, the proteids also undergo a change, which does not add to 
their nutritive value. 

DIFFICULT FEEDING CASES 

Under this heading will be considered the acutely difficult cases, 
those seen in the newly born or during the first month of life. Maras- 
mus and malnutrition will not be referred to here, as these sub- 
jects are considered under their respective headings. 

Not a few healthy infants for whom the breast-feeding is impos- 
sible show intolerance of cow's milk even when it is given very much 
diluted with lime-water or otherwise. In these infants the intoler- 
ance is usually of the casein of the cow's milk. The child suffers from 
colic, oftentimes to an extreme degree, crying five or six or more 
hours out of every twenty-four. Generally there is constipation. The 
stools are usually hard and dry, and when passed, are often composed 
of broken masses of fecal matter. In some, however, there will be 
loose watery stools containing many milk curds. The abdomen is 
usually distended and there may be vomiting, but this is seldom 
an active symptom. The child remains stationary or loses in weight. 
If suitable nutrition is not forthcoming, he rapidly develops a con- 
dition of malnutrition or marasmus. 

Treatment. — Whey-feeding. — In some of these infants the feeding 
of whey (page 107) or cream largely diluted may be successful (page 
98). In not a few, however, the small amount, about 0.3 percent, 
of casein which cannot be removed from the whey is sufficient to 
cause marked symptoms of indigestion. The addition of citrate of 
soda, one grain to the ounce (page 107), may be attempted here for 
the purpose of facilitating the digestion of the casein. A few days' 
trial may determine whether it will be of any service. 

Malt-soup Feeding (page 109). — This method has aided me in 
solving many difficult feeding problems. 

The Wet-nurse. — The use of peptonized milk mixtures is rarely 
successful with these infants. If the whey or diluted cream or the 
peptonization of the food or malt-soup feeding is not successful, I 
invariably advise a wet-nurse if the family can afford the so-called 
luxury. It is important in the management of one of these cases 
for the physician to know when he is beaten. A case should never 
be experimented with to the point of marasmus and exhaustion before 
securing a wet-nurse, for by this time the digestion may be so thor- 
oughly deranged that her milk will fail to nourish the child. 

Condensed Milk. — When the wet-nurse is impossible, it is not wise 
to attempt the forcing of fresh cow's milk or cream mixtures. Con- 
densed milk should now be resorted to. The proteid of condensed 
milk is often very readily assimilated by the most delicate infant and 
furnishes a valuable means of nutrition in not a few cases until the 



DIFFICULT FEEDING CASES II 3 

infant is able to digest better food. It is to be understood, however, 
that condensed milk is but a temporary expedient. The infants will 
take it with comfort, and temporarily will thrive on it, oftentimes 
when cow's milk in any dilution or process of adaptation is impossible. 
When beginning the use of condensed milk it is best to begin with 
small quantities — not more than one dram in the boiled water diluent 
of two or three ounces. In some cases, at first, even one-half dram 
answers better. Later the strength may be increased to from two to 
four drams if it is found to agree, the amount depending somewhat 
upon the age of the patient. When the condensed milk is found to 
agree, in order to give as much nourishment as possible, No. i 
barley-water or Granum- water (page 130) may be used as a diluent. 

Cow's Milk. — ^When the child has remained comfortable for three 
or four weeks on some such scheme of feeding, with or without a gain 
in weight, one feeding daily of a cow's-milk mixture may replace a 
feeding of condensed milk. A cow's-milk mixture should always be 
given of a weaker strength than the child's age calls for. In spite 
of the dilution it may occasion indigestion, colic, and the passage of 
curds. In such an event the condensed milk and its diluent must 
again be the sole diet for two or three weeks, when the use of cow's 
milk may again be attempted. In case this one feeding of cow's milk 
is taken without inconvenience, a second feeding may replace another 
condensed-milk feeding in a few days or a week. In this way the 
number of cow's-milk feedings may gradually be increased until the 
child is taking a rational diet of cow's milk alone. I have a most 
difficult feeding case under my care at the present time. A six- 
months-old baby is taking daily three feedings of condensed milk 
and three of cow's milk. Attempts have been made to give him the 
fourth feeding of cow's milk, but invariably with disastrous results. 
He is slightly under weight, but is in a fair general condition. 

I have successfully managed a great many of these difficult 
feeding infants as described above, the cow's-milk feeding not being 
commenced until the condensed milk is well taken and the child 
gaining, when the cow's-milk feeding is gradually advanced so that 
when the child is three months old it will be taking daily and assim- 
ilating two or three feedings of cow's milk; when six mo'nths old and 
sometimes earlier, he will be on entire cow's-milk feedings suitable 
for his age. I have found that by the above method the desired end 
of complete cow's-milk feeding is reached sooner than when small 
quantities of cow's milk are added to the condensed-milk mixture. 

In beginning cow's milk it is best to give it at the first or 
second feeding in the morning, when the digestive powers are 
stronger than they are later in the day. When the second cow's-milk 
feeding is given it should never immediately follow the first. The 
cow's milk and the condensed milk should be alternated until more 
than one-half of the daily feedings are of cow's milk. 
8 



114 NUTRITION AND GROWTH 

Idiosyncrasies as to Cow's Milk. — In rare instances, cases are 
encountered in which there exists an intolerance of cow's milk or 
any form of food which contains cow's milk, including condensed 
milk, and all the malted foods containing desiccated cow's milk. 
In such cases the use of any of these substances as foods produces 
illness of such an alarming type as to necessitate its prompt discon- 
tinuance. The only hope for infants thus constituted is a wet-nurse. 

Illustrative Cases. — The best illustration of milk idiosyncrasy that 
I have observed occurred in my own family. A healthy full-term 
female infant whose birth- weight was seven pounds twelve ounces was 
nursed by her mother with indifferent success for two weeks, when the 
supply failed absolutely. Feeding with a most carefully prepared 
modified cow's milk was begun. The child refused the food and two 
drams were forced. This was followed, in a few moments, by vomiting 
and retching, which continued at intervals for twenty-four hours, with 
collapse and exhaustion to an extreme degree. A wet-nurse was 
secured, the breast was well taken, and the milk agreed perfectly. 
In three days the wet-nurse's milk began to fail and was entirely 
lost in twenty-four hours. A weak dilution of condensed milk was 
then given, with results almost as disastrous as before. The child 
at this time weighed six pounds four ounces and showed all the 
symptoms of early marasmus. A second wet-nurse was secured, 
whose milk also failed in a few days. Before dismissing her, however, 
a third was engaged, on whose milk the child thrived most satisfac- 
torily. When three months of age a weak cow's-milk mixture 
prepared by the Walker-Gordon Laboratory was given. The child 
refused it, and one-half ounce was forced. As on the previous 
occasion, vomiting with prostration bordering on collapse was the 
outcome. The child vomited at frequent intervals for twelve hours 
and the breast was refused for twelve hours longer. The giving of 
cow's milk was not again attempted until the child was nine 
months old, a wet-nurse being employed. She was then strong 
and vigorous and weighed eighteen pounds. Two drams of a cow's- 
milk mixture suitable for a child three months of age were given. 
It produced nausea and vomiting as though an equal quantity of 
syrup of ipecac had been given, but without any more serious dis- 
turbance. At this time the wet-nurse's milk began to fail. The 
breast-milk nutrition was assisted by the use of a cereal made into a 
thick gruel. Oatmeal in the form of a gruel to which sugar was 
added was given, largely because of its high-proteid content. Beef- 
juice, scraped beef, and pure cod-liver oil were also begun about 
this time. When one year of age a portion of a soft ^gg was added 
to the diet. Zwieback and bread crusts soaked in sugar-water were 
also used. These solid substances were given two or three times a 
day, after which the child was nursed. Pure cod-liver oil was 
almost continuously given during the second year. Butter fat 



STERILIZATION AND PASTEURIZATION OF MILK II5 

could be taken without inconvenience when she was one year of age. 
Following out the above lines of treatment, the child was w^eaned 
when thirteen months of age. She has since been fed with an entire 
absence of cow's milk from the diet. She is now six years of age. 
Her weight is fifty-five pounds, height forty-eight inches. She is 
normal in every respect, but six ounces of milk given at one time 
w411 produce a coated tongue, foul breath, constipation, and excessive 
irritability, which is entirely foreign to her nature. 

I had a similar experience in the case of a patient — a boy now 
four years of age who has never been able to take cow's milk. He 
also is above the average in weight, height, and vitality. I have 
had a number of these cases which could not take milk up to the 
eighteenth month or second year. I have had, in all, five cases 
that could not tolerate milk in any appreciable amount until after 
the fifth year was passed. 

STERILIZATION AND PASTEURIZATION OF MILK 
The sterilization and pasteurization of milk, as the terms imply, 
are for purposes of preser\'-ation. By sterilized milk w^e understand 
milk that is heated to the boiling-point and maintained at that 
temperature, 212° F., for twenty minutes. The effect of sterilization 
is the destruction of the pathogenic bacteria, but it will not destroy 
the spores. Dr. R. G. Freeman's most recent observations show that 
heating the milk to 140° F. and maintaining it at this point for one 
hour is of advantage, in that the bactericidal effects are as good 
as when a higher temperature is used. At the same time the lower 
temperature produces less chemical change in the milk. Pasteuriza- 
tion consists in heating the milk to 167° F., maintaining it at that 
temperature for thirty minutes, and then quickly cooling it. The 
effect of sterilization and the rapid cooling is to kill the existing bac- 
teria, thus preventing, temporarily, further bacterial growth in the 
milk. The heating of milk to this high degree of temperature — 212° 
F. (the boiling-point) ^ — produces certain changes in the milk. The 
lactalbumin is coagulated, the lime salts are rendered insoluble, and 
the casein is rendered much more difficult of digestion, so that the 
heating of milk in this way renders it more difficult of digestion and 
lessens its nutritive value. 

Results of Sterilization. — Constipation is one of the unfavorable 
results of sterilizing milk. The peculiar taste produced by boiling is 
another of the disagreeable features connected with it. The cooking 
of the milk destroys certain of its nutritional properties but little un- 
derstood, the result of which may be scurvy, rachitis, or some other 
form of malnutrition. Sterilization, however, is in certain conditions 
necessary. The milk which is boiled in a bottle which is properly 
coA^ered is " sterilized milk," but if the sterilization is to be carried on 
day after day an Arnold sterilizer (Fig. 14) should be used. For pur- 
poses of pasteurization the Freeman pasteurizer (Fig. 15) is recom- 



ii6 



NUTRITION AND GROWTH 



mended. Pasteurization makes less change in the character of the 
milk content ; consequently there is less interference with its nutritive 
value. The temperature, too, 167° F., is sufficiently high to 
destroy pathogenic bacteria, including the Bacterium lactis and 
the Bacterium aerogenes, and hence acts as a valuable preservative, 
particularly during hot weather. But heating the milk to this 
degree exerts little influence in causing constipation, nor does it 
change the taste of the milk. 

Pasteurization Safest for Exclusive Use. — As to the feeding of 
milk, whether it shall be given sterilized, pasteurized, or raw, end- 
less discussion has arisen in the press and in medical societies. Bach 
method has its advocates. Among the pediatrists at the present 
time, some contend that milk should be sterilized, regardless of the 

season of the year, the character 
of the milk, or the station in life of 
the patient ; others maintain that 
invariably it should be given raw, 
regardless of the above-mentioned 
conditions; while still others are 
devoted to pasteurization. If any 
of the methods were to be used 
exclusively, pasteurization, being 
the safest, should be selected. 
Judging from my own experience 
in the matter of the heating of 
milk for infant foods, the sub- 
ject should be considered from a 
broad standpoint. There is no 
one way of heating milk that is 
invariably the best way. Ac- 
cording to my observation, which 
covers every class of society, 
there are several factors which determine which is the proper pro- 
cedure in a given case. 

Raw Milk Preferred if Fresh and Pure. — There is no doubt what- 
ever that the less the milk is heated, the better food it is for the 
baby, assuming that it is clean when procured and can be kept clean 
and sweet until it is used. (See Cow's Milk, page 83.) This is possible 
in some of our dairies of the better class ; it is possible with many 
who live in the country, or who go to the country for the summer 
and who keep their own cows or who get their milk-supply from a 
neighboring source which they can control. Under such conditions 
the milk may be given raw during the entire year. 

When the milk has to be shipped a considerable distance during 
the summer, when its safety depends upon the industry and care of 
the employees of a milk farm, I find it advisable to pasteurize the 




Fig. 14.— Arnold Sterilizer. 



STERILIZATION AND PASTEURIZATION OF MILK 



117 



milk during the heated term; therefore the majority of my private 
feeding cases get raw milk during eight months of the year and pas- 
teurized milk four months. Sterilized milk is never used among 
these patients except when preparing for an ocean voyage (see Milk 
for Traveling, page 122) or for a long-distance journey by land. 
Among out-patients, after feeding many thousands of them I find 
the following scheme the safest: From May ist until October ist, 
the milk is boiled (sterilized). These people, most of them, cannot 
afford a pasteurizer or sterilizer or understand the use of either. 
From October ist to 
May ist, the milk is 
given raw. Pasteuri- 
zation would be pref- 
erable, but it is possi- 
ble with but very few 
dispensary patients. 
Bven the giving of 




Fig. 15.— Freeman Pasteurizer. 



cooked milk, which unquestionably often becomes infected after 
cooking, is attended with no little risk to the child, as is shown 
by the death records of bottle babies during the summer. The giv- 
ing of the cheap market milk raw to infants of the tenements during 
the heated term in any large city can only help to increase the 
terrible mortality of this season. 

The object of heating the milk should always be explained to 
the mother so that she may appreciate the necessity of keeping it 
carefully covered and properly caring for it afterward. The idea 
is prevalent among uninformed people that after sterilization but 
little further protection is required. When I am satisfied the out- 
patients have not the intelligence nor the requirements for keeping 



Il8 NUTRITION AND GROWTH 

cow's milk during the summer, such as an ice-box and ice, I discon- 
tinue the ordinary milk-feeding for the hot months and use condensed 
milk instead (page 105). 

CONDENSED MILK 

Condensed milk is in the market in three forms — fresh condensed 
milk sold in bulk, condensed milk sold in hermetically sealed cans, 
and evaporated cream, sold also in hermetically sealed cans. The 
evaporated cream usually contains no more fat than does condensed 
milk; in fact, it is condensed milk without the addition of sugar, 
which acts as a preservative. They are put up in small cans and 
soon become putrid after opening. Therefore the contents of a 
can should be used only on the day it is opened. Of the condensed 
milk, I prefer the sweetened variety, of which there are many kinds 
showing slight variation in the analysis. The Eagle Brand of 
Borden is that which I usually employ, an analysis^ of which showed 
it to contain : 

Fat 8.8 percent 

Sugar . .52.2 

Total proteid 9.3 

Total solids 72.2 

Ash ... 1.9 

Water 27.8 

The following combinations of condensed milk with barley-water 
may be found useful in the various ages indicated : 

Under three months of age: Condensed milk, one-half to one 
even teaspoonful; barley-water, two to four ounces. 

Third to sixth month: Condensed milk, one to two even tea- 
spoonfuls ; barley-water, four to six ounces. 

Sixth to ninth month: Condensed milk, two to three even tea- 
spoonfuls; barley-water, six to eight ounces. 

Ninth to twelfth month: Condensed milk, three even teaspoonf uls ; 
b)arley-water, eight ounces. 

It will be seen that when condensed milk is diluted from ten to 
twenty times, we have a food weak in fat and weak in proteid. It 
should never be selected as a permanent diet unless poverty neces- 
sitates it or unless it is the only milk food the patient can digest. 
For temporary purposes it is often useful, as is shown in 
different portions of this book (see index). Where cow's milk can- 
not be used in a given case, and condensed milk must be continued, 
it should be fortified with a cereal gruel of barley or oatmeal; pure 
cod-liver oil should also be given to make up for the deficiency in fat 
in the food. 

^Analysis made for the author by Dr. Frederick Sondern, of New York. 



PEPTONIZED MILK 119 



PEPTONIZED MILK 

Milk is peptonized, or predigested, for the purpose of partially 
or completely digesting the proteid before it is given to the patient. 
As a means of assistance in making a milk food assimilable its field 
of usefulness is limited. The process referred to (page 109) has been 
the one most successful with me. So-called complete peptonization 
produces a product with a decidedly bitter taste, and but few^ children 
will take it. Peptonized milk, however, has other uses than as a means 
of daily feeding. Peptonized milk in which there is a complete 
conversion of the casein has been most useful in two types of cases. 

For Gavage. — During acute or chronic illness when a child cannot 
take food by the natural method, as in diphtheritic paralysis, or 
when he will not swallow on account of an acute inflammatory 
disease of the throat such as peritonsilHtis, retropharyngeal abscess, 
or retropharyngeal adenitis, or when he is in a comatose condi- 
tion from any cause except intestinal infection, the feeding of 
completely peptonized milk by gavage (page 140) is of inestimable 
value. In such conditions, as a valuable aid in nutrition, frequent 
reference is made to it throughout this book. 

For Nutrient Enema. — In conditions when stomach- feeding is 
impossible either by gavage or the natural method — conditions met 
with in persistent vomiting due to acute cerebral diseases, in recur- 
rent vomiting, in acute gastric indigestion — and as an accessory 
means of feeding when sufficient nourishment cannot be taken by the 
stomach, the colon-feeding of completely peptonized skimmed milk 
has a decided field of usefulness, and in this way I often employ it. 
Feeding by means of the bowel, however, is usually possible in children 
for a few days only, because of the local irritation produced by the 
nutriment and by the passage of the tube. Skimmed milk, pepton- 
ized, with the addition of the white of egg makes the best nutrient 
enema that I have used (page 145). It should be given at a tem- 
perature between 90° and 95° F. at from six to eight-hour intervals. 
The tube should be introduced at least nine inches. In cases of re- 
current vomiting I have repeatedly seen both hunger and thirst 
relieved by feeding in this way. The following are the different 
methods for the peptonization of milk. 

Peptonization. — Immediate Process. — Fifteen minutes before 
feeding add from one-eighth to one-quarter of the contents of a Fair- 
child peptonizing tube to the milk mixture which is in the nursing- 
bottle ready for use. Place the bottle in water at a temperature of 
from 110° to 120° F., and let it remain until fifteen minutes have 
elapsed. The amount of the powder used and the degree of heat of 
the water depend, of course, upon the amount of milk in the nursing- 
bottle. 

Cold Process. — Put four ounces of cold water into a clean quart 



I20 NUTRITION AND GROWTH 

bottle and dissolve in it, by shaking thoroughly, the powder con- 
tained in one of the Fairchild peptonizing tubes; add a pint of cold 
fresh milk, shake the bottle again, and immediately place it upon ice — ■ 
directly in contact with it. 

The bottle should always be well shaken before and after pouring 
out a portion of its contents. 

Partially Peptonized Milk.^ — Put four ounces of cold water and 
the powder contained in one of the Fairchild peptonizing tubes into 
a clean saucepan, and stir well; add a pint of cold fresh milk and 
heat with constant stirring to the boiling-point. The heat should 
be so applied that the milk will come to a boil in ten minutes. Let 
it cool until lukewarm, then strain into a clean bottle or glass jar, 
cork tightly and keep in a cold place. The bottle or jar should always 
be well shaken before and after pouring out a portion. 

Partially peptonized milk, if properly prepared, will not become 
bitter. 

Completely Peptonized Milk. — Put four ounces of cold water and 
the powder contained in one of the Fairchild peptonizing tubes into 
a clean quart bottle and shake thoroughly; add a pint of cold fresh 
milk and shake again; then place the bottle in a pail or kettle of 
warm water — about 115° F. , or not too hot to immerse the hand in 
it without discomfort. Keep the bottle in the water-bath for thirty 
minutes. Put it immediately upon ice — directly in contact with it. 

THE FEEDING OF BUTTERMILK, SOUR MILK, FERMENTED MILK 
A great deal of literature has appeared during the past few years 
relating to the use of different forms of soured milk for infant feeding. 
Buttermilk has been used for this purpose in Holland for a great 
many years. Various Continental and American observers report 
having used it extensivel}^ and with gratifying results. 

During the summer of 1906 the use of buttermilk as a means 
of infant feeding was begun at the Babies' Hospital by Dr. L. Emmett 
Holt, and continued during the summer service by Dr. L. E. Le Fetra 
and myself. Our results at that time with a considerable number of 
cases were not satisfactory and its use was discontinued. It was 
thought that a possible cause of lack of favorable results might rest 
with the buttermilk, that it was not as good as used by others, 
although every care was used and no expense spared to secure the 
best. 

During the summer of 1908 the feeding of artificially soured 
milk, using tablets containing a pure strain of the lactic acid ba- 
cillus, was again attempted along somewhat different lines. The 
milk was prepared in the diet kitchen of the hospital, using the tab- 
lets in question, prepared by dissolving a tablet in four ounces of 
water. This was mixed with one quart of milk and allowed to stand 
at room-temperature from twenty-four to forty-eight hours, when a 



THB FEEDING OF BUTTERMILK, SOUR MILK, FERMENTED MILK 121 

delicious full fat fermented milk was produced. This was diluted 
with water or cereal water, with the addition of milk or cane-sugar, 
to bring the carbohydrate to proper proportions, the dilution of the 
milk depending upon the age and the assumed digestive capacity of 
the patient. 

The child's caloric requirements were considered in each patient. 
It was used in thirty-four cases, full milk being employed in thirty 
cases, skimmed milk in four cases. Two groups of children were 
treated. The first group, fifteen in number, were distinctly feeding 
cases, and came to the hospital because they were not thriving. They 
varied in age from one to sixteen months. Twelve were less than 
six months of age. In eleven of these fifteen, full milk was used. In 
the remaining four, milk had been skimmed. In the eleven in which 
the soured full milk was used, every child but one lost, and this gained 
but one-half ounce in two weeks. Two babies were on the food two 
days, one practically refusing it, the other making a loss of four ounces 
in the two days. Five were given the milk from three to six da vs. 
Among these, the greatest loss was nine ounces, the smallest, one and 
one-half ounces. One child in fair condition lost six ounces in three 
days without a sign of illness and took the food well. The four that 
were given the soured skimmed milk fared as badly. One onlv gained 
one and one-half ounce in ten days and made a prompt gain when 
other food was used. The other three failed rapidly and died from 
inanition, two after four days, the other after nine days. 

The results were so disastrous that the observation on the feeding 
cases was discontinued at this point. The children were not made ill 
by the soured milk. They simply faded away under its use. 

In a large experience in hospital and private work, I have never 
seen as typical a clinical picture of depression, prostration, and pallor 
as shown by these soured milk-fed babies. 

The second group comprised infants who were given the soured 
milk after intestinal disease. It is most difficult, as is well known, 
after a severe attack of summer diarrhea to bring the child to a 
thriving cow's milk diet. It was thought that this condition of pro- 
tracted convalescence could be shortened in the use of the soured 
milk. It was thus used in nineteen cases. Its use was begun after 
the subsidence of the acute symptoms, when freer feeding might 
safely be instituted. The patients ranged in age from one month 
to fourteen months. Nine were over six months, of which number, 
two were over one year. The youngest was one month old. The 
milk was used as in group one. The duration of its use was from 
one to sixteen days. The milk was refused absolutely by two. Four 
were given the food from two to four days. The early discontinua- 
tion of the food was the result of its refusal by two, and by very 
rapid loss in weight in the others. But four gained in weight. 



122 NUTRITION AND GROWTH 

One gained 7 ounces in sixteen days 
One gained 2 ounces in sixteen days 
One gained 10 ounces in fifteen days 
One gained i ounce in six days 
One remained stationary for twelve days 
One lost 2 ounces in ten days 
One lost 12 ounces in eleven days 
One lost 24 ounces in nine days 
One lost 12 ounces in twelve days 
One lost 8 ounces in eight days 
One lost 7 ounces in seven days 
The other lost, but smaller amounts. 

It will be seen that but tv^o in this series made a satisfactory show- 
ing. By our usual methods of resuming stronger feeding with diluted 
milk or with condensed milk, the results are incomparably better. 
It would hardly seem necessary to add that we do not advise treat- 
ment of milk with the lactic acid bacillus for purposes of infant feed- 
ing. These results were so far inferior to those following our usual 
methods of treatment that all observations were discontinued at this 
point. 

MILK FOR TRAVELING 

In making long journeys with infants by land or water, the 
feeding of the child is an important matter, and advice is often 
sought by mothers who wish to make the contemplated trip with the 
least possible risk. It is, of course, desirable that no change be made 
in the milk commonly used, and there are means of treating the 
milk and of keeping it which enable us to assure the patient of 
reasonable safety. It is my custom with city children to have the 
milk prepared at the Walker-Gordon Laboratory, where at a trifling 
expense small ice-boxes can be obtained which contain sufhcient 
space for a few days' supply of milk and which can be conveniently 
carried on cars and boats. They have also larger boxes with a 
capacity of twelve quarts which may be used for an ocean voyage. 
The smaller box will need refilling with ice, once or twice a day, 
which is usually readily secured. The larger box for ocean voyages 
is packed in ice and placed in a cold-storage room of the vessel 
and will not need repacking during the trip. The milk prepared 
for a journey should be cooled to 45° F. as soon as it is drawn, and 
kept at this temperature until it can be sterilized at a temperature 
of 212° F. for twenty minutes. It then should be cooled rapidly to 
at least 50° F. and kept at this point until used. These directions 
can be carried out by any intelligent family. When this is done the 
milk will be safe for use for the time required — from seven to eight 
days. Of course, laboratory milk is available for comparatively 
few. But the suggestion as to the making of an ice-box can be 
followed in any town or village, so that a milk laboratory is not 
essential. All that is required is the ice-box, the quart fruit jars 
or quart milk bottles, and clean milk. Those who for any reason 



THE PROPRIETARY FOODS 1 23 

cannot avail themselves of the milk thus preserved will find in canned 
condensed milk a fairly good substitute. If kept on ice and wrapped 
in a sterile towel, a can of condensed milk may safely be used for three 
days after opening. Formulas suited for the various months of 
infancy will be found in the section on Condensed Milk (page 118). 

THE PROPRIETARY FOODS 

The foods on the market prepared for purposes of infant-feeding 
are very numerous. From our knowledge of the composition 
of mother's milk we learn what nutritional elements and approx- 
imately in what relative proportions these elements must exist in 
order to supply the child with the food which nature intended him 
to have. The examination of the milk of thousands of nursing 
women shows that it ranges from 2.5 to 4 percent fat, 6 to 7 percent 
sugar, and i to 1.5 percent proteid. These figures may be put down 
as the normal limits of human milk, and they are so, simply because 
the infant will thrive and grow when the nutritional elements in 
approximately the above proportions are supplied to him. It is 
within these Hmits that the food must be kept in order that there 
may be normal growth and development; though, of course, wide 
variations from these may be of temporary occurrence. While 
the child may exist and temporarily do fairly wxll on a percent- 
age of fat lower than 2.5, he wdll invariably show defective growth 
if the proteid remains persistently under i percent. The chief 
disadvantage in the infant foods which are used without the addition 
of cow's milk, lies in the fact that they do not contain the nutritional 
elements as they exist in normal breast-milk, and besides, of neces- 
sity, they are all cooked foods. 

In selecting a substitute for mother's milk (page 82) one point 
is to be kept in mind, viz., the substitute should contain, in a readily 
assimilable form, the nutritional elements in approximately the 
proportions and forms in which they exist in mother's milk. All 
other feeding is defective. It is not well to put too much reliance 
on the analysis sometimes published by the proprietary^ food manu- 
facturer. This type of food is decidedly weak in animal fat, for the 
reason that there is no means of keeping more than a small percentage 
of it in a food without its becoming rancid. When considerable 
percentages are indicated in the analysis it is certain that it does not 
consist of butter fat. The quantity of animal milk proteid is likewise 
deficient, and what is present has been cooked, thus detracting 
materially from its value in infant nutrition. Scurvy is not an 
infrequent result of the exclusive use of these foods. 

The Uses of Proprietary Dried-milk Foods. — It is to be remembered 
that this type of food is condemned because of its being an unsuitable 
food when used exclusively and persistently. Hysterical general 
condemnation of the proprietary infant foods is an injustice. 
Throughout this book, the proprietary foods will be found mentioned 



124 NUTRITION AND GROWTH 

from time to time and their uses dwelt upon. In constipation in 
"runabout" and older children who are on a general diet, the impor- 
tance of milk in the nutrition is a secondary one, and is often an 
important factor in the production of constipation. In these cases 
cow's milk may be replaced by one of the proprietary dried-milk 
foods which has a laxative effect, with a good deal of advantage. 
I sometimes employ them further in other disordered states. During 
acute illness and in convalescence from illness and in certain forms 
of malnutrition they are usually readily digested and may help us 
over difficult places. 

Proprietary Foods to Which Fresh Cow's Milk is Added. — These 
are not foods in the usual acceptation of the term, and if they are 
used alone independent of milk the patient will soon present a sorry 
spectacle. They are sugars largely, being composed of maltose 
and dextrose, which are derived from starch. Some contain a con- 
siderable quantity of unconverted starch. When added to the 
water and milk mixtures they furnish the soluble carbohydrates and 
free starch, and thus fulfil this function in the food with as good 
results as, but usually no better than, would milk-sugar and a cereal 
gruel. Maltose is a laxative sugar. In case of constipation in the 
bottle-fed it may replace the milk-sugar in equal quantity, and as 
such may be used with decided advantage in some cases. In other 
cases this change to maltose is without effect. The claim that 
when added to cow's milk these proprietary foods increase the lia- 
bility to scurvy is without foundation. If the milk is given uncooked, 
the child will not have scurvy, regardless of the nature of the 
carbohydrate; if the milk is heated to i6o° or 170° F., the child may 
have scurvy regardless of the carbohydrates. 

The exploiting of photographs of crowing, fat, red-cheeked 
babies which are used to illustrate the supposed virtues of this or 
that manufacturer's food composed principally of maltose, is not a 
very high-minded procedure on the part of the manufacturer who 
thus stoops to steal the credit which belongs to a cow! According 
to my observation, the statement that the addition of maltose to 
cow's milk facilitates its digestion is unfounded. I have tried it in 
many cases, but have never been able in consequence to use a stronger 
cow's-milk mixture, a higher proteid. The true test of such a meas- 
ure is its use in the delicate, and in difficult feeding cases, and not in 
well babies who thrive regardless of the carbohydrate employed. 
The maltose preparations, then, in the sense that they may contain a 
small amount of proteid and a laxative sugar, are useful and to be 
recommended when such a carbohydrate is needed. 

The Proprietary Beef Foods. — Numerous preparations of this 
nature are on the market and there has been abundant opportunity 
to test their value. Without going into a lengthy discussion as to 
how and under what conditions these preparations have been used, 
it is sufficient to say that as a means of nutrition in children they 



cKRKAiy gruels; starch-feeding 125 

play a very unimportant part. Their principal use is in illness, in 
which they act as a stimulant, and to a less degree as a food. They 
all make weak proteid mixtures when diluted so that the child can 
take them. The possibility of supplying any great amount of nu- 
trition to the economy by their use is impossible ; occasionally, how- 
ever, they may be used to advantage. When milk is withdrawn, they 
may be added to the cereal gruel substitute. If there is diarrhea, great 
care must be exercised, as the proprietary beef preparations as well 
as beef-juice may increase it. On account of the creatinin which 
they contain, they should not be given in any of the forms of nephri- 
tis. Another feature which limits their use is that a child soon tires 
of them. They can rarely be given more than two or three times in 
twenty-four hours. Valentine's is the preparation I usually select. 
It may be given in solution — one-quarter to one-half teaspoonful 
to six ounces of the diluent. 

CEREAL GRUELS; STARCH-FEEDING 
Much discussion has taken place during the past few years- as to 
the use of cereals in infant -feeding. 

The cereals consist of plant embryos surrounded by a mass of 
highly nutritious proteids and carbohydrates in the form of starch 
which nourishes the embryonic plant until it becomes rooted in the 
ground. As the developing plant needs nourishment it converts 
the starch into dextrin and maltose. Cereals are analogous to 
eggs in that the germ is packed away in a supply of exceedingly 
nutritious food which in the process of development it converts into 
tissue. Almost all of the prepared infant foods are made from cereal 
flours, with or without the addition of a little dried milk or sugar; 
or from cereals in which the starch has been transformed into dextrin 
and maltose. The proprietary meal foods which consist of baked 
flours of different kinds are useful aids in infant-feeding and most 
useful as milk substitutes when milk must temporarily be withheld. 
The conversion of starch into dextrin by the baking process is so 
slight that it may be ignored. Robinson's barley flour, Cereo Co.'s 
barley flour and the other gruel flours, and Imperial Granum (baked 
wheat flour) require boiling before use. They may be prepared 
according to the instructions given in the formulary (page 129). 
It is my custom in bottle-feeding to begin with a cereal from the 
fifth to the seventh month, b}^ using a cereal water as a diluent of 
the milk mixture. For this purpose barley or granum is usually 
employed. Very often in out-patient work I begin with a cereal 
diluent very early in life in order to make the food mixture more 
nutritious. This method of feeding is useful when accurate modi- 
fications are not possible and when the child for any reason cannot 
take a milk formula as strong as its age and nutritional requirements 
demand. Such cases are frequently seen in the marasmic, the 
malnutrition, and the difficult feeding class. The addition of 



126 NUTRITION AND GROWTH 

two or three table spoonfuls of flour to the daily food will increase 
its nutritive value not a little. That boiled starch may be digested 
by the youngest and most marasmic infant has been proved under 
my own observations. 

The principal use of these flours, however, is in the gastro-enteric 
diseases, where they may with safety replace the milk for considerable 
periods of time. In the treatment of the acute intestinal diseases 
their uses are repeatedly referred to. By eliminating milk from the 
diet and giving carbohydrates, a putrefactive culture-field is removed 
and a less favorable soil is furnished for the development of the 
intestinal bacteria; further, there are no by-products formed to 
produce intestinal toxemia or kidney irritation. Two even table- 
spoonfuls of these flours to one pint of water give approximately a 
food strength of 0.07 percent fat, 0.3 percent proteid, 2 percent car- 
bohydrate. In order to increase the nutritive value, cane-sugar may 
be added in sufficient quantity to bring the carbohydrate percentage 
up to five. The addition of the sugar also makes the cereal more 
palatable, and it will therefore be taken more readily by the patient. 

During an invasion of scarlet fever, pneumonia, or any of the 
illnesses of childhood which may be accompanied by great prostra- 
tion, the usual foods, whatever their nature, should be withheld, 
and the cereal gruel alone or mixed with chicken or mutton broth 
used as a very satisfactory substitute. Likewise later in the disease 
it is never well to give full milk while fever and prostration are 
present. A useful field for the cereal gruels is as diluents of the milk 
in conditions where this combination must often furnish the nutrition 
for days. The use of the baked-flour gruels, with sugar or without, 
as a means of nutrition should be continued only during the active 
symptoms of the disease, whether it is scarlet fever or one of the 
intestinal diseases. In no sense are these gruels advocated as ex- 
clusive foods for infants or for growing children. I have seen many 
cases where this error has been made with most disastrous results. 

The Infant's Capacity for Starch Digestion Proved by Experi- 
ment. — It has been claimed with more or less tenacity by different 
writers that the young infant possesses no capacity for starch 
digestion. Two years ago a study of starch digestion in infants of 
different ages was undertaken at my suggestion at the New York 
Infant Asylum. In the first series of sixty cases, 324 stool examina- 
tions were made, for purposes of observation on exclusively starch- 
fed children. 

Boiled barley flour in the form of a gruel in amounts of from 142 to 
1560 grains in twenty-four hours was given, the usual quantity being 
from 400 to 500 grains. In testing for starch in the stools, the 
von Jaksch iodin method was employed. In thirty-three cases 
the stools were persistently negative, five examinations having been 
made on five successive days ; of these, eleven were under six months 
of age. One, who was nineteen days old, took 142 grains of starch 



CEREAL gruels; starch-feeding 127 

daily, and the stools were negative to the two examinations made 
on two successive days. One, twenty-one days old, took 225 grains 
every twenty-four hours. To one, five months and twenty-six days 
old, 375 grains daily were given. In each of these cases five examin- 
ations were made, all being negative. To one five and a half 
months of age 450 grains were given for three successive days. 
It was then decided to increase the starch and test his digestive capac- 
ity. There were accordingly^ given him 1560 grains daily for two 
days. The stools failed to respond to the iodin test. One was one 
month and twenty-two days old. The patient was thin and he had 
diarrhea. Four hundred grains were given the first day, followed 
by a negative stool. Three hundred and ninety grains were given 
on each of four successive days, the stools remaining negative. To 
another child, one month and nineteen days old, 185 grains were given 
for three days, with stools negative. The starch was then increased to 
300 grains for two da^^s, the stools still remaining negative. In seven 
cases the stools were persistently positive, showing the presence 
of starch in considerable amount at each examination. In twenty 
cases the reactions were sometimes positive and sometimes negative. 
From these examinations it was shown that of the sixty cases in 
question, forty-one showed a good starch capacity and nineteen an in- 
different or poor starch capacity. That some of the starch may have 
undergone fermentation in the intestine is, of course, possible. How- 
ever, it could not have been a factor of great consequence, for the pa- 
tients did not show more than the usual bowel distention. Dextrin 
was present at times in over one-half the cases, thus showing only 
a partial conversion from the presence of a starch enzyme. In all 
these children subjected to the test, a fair degree of nutrition was 
maintained during the period of the exclusive starch diet. Several 
of the starch-fed infants in which the stools were negative to iodin 
were very young and very delicate. This led us to undertake a 
study of the stools of infants fed exclusively on the breast, with a 
view of determining, if possible, the presence of starch-digesting 
enzyme or enzvmes in the feces, 161 tests being made of the stools 
of twenty-six children. The ages were : under two w^eks, twenty- 
two; between one and two months, three; one, the oldest child, was 
two and one-half months old. The tests were conducted as follows: 
A solution of starch, i ooo, was boiled for fifteen minutes. From 
one to four drams of this solution were then put into a test-tube, and 
to this a dilute Tugol solution was added and the tube marked for 
control. To another boiled solution of starch of similar strength, 
Fehling's solution was added to determine the presence of sugar, 
which, of course, was absent. In another tube a portion of feces 
in plain boiled water was tested for sugar and always found negative. 
The observations were thus protected by three controls. In still 
another tube an equal amount of a i : 500 starch solution was boiled 
for fifteen minutes and a definite amount of feces by weight was 



128 NUTRITION AND GROWTH 

added. The contents were then thoroughly shaken and placed in a 
water-bath, which was maintained at a temperature of ioo° F. for 
one-half hour. The solution was then tested for sugar with Fehling's 
solution. In every case the presence of sugar was indicated, thus 
proving the presence of something in the feces which transformed 
the starch into maltose. The observations agree with those of 
von Jaksch, who proved a starch-converting ferment in twenty-eight 
out of thirty cases, and with those of Moro, who proved the same 
thing in thirty-eight out of forty cases. 

It was found that the converting capacity of the feces for starch 
was in the proportion of one grain of feces to about one-twentieth 
grain of starch, this amount being required for the complete con- 
version of the starch into sugar. In one case there was a capacity 
of but one-sixtieth grain of starch to one grain of feces. In three, 
one grain of feces converted one-tenth grain of starch. When 
stronger starch solutions were used, there was a response both with 
the Lugol and Fehling solutions, showing a partial conversion. In 
three, the examinations began on the day of birth and were continued 
for several days, four examinations being made in each case. Six 
were commenced on the second day and continued for four days. 
One premature baby (eight months) which lived six days and 
weighed four pounds four ounces showed a power of conversion of one 
grain of feces to one-thirty-second grain of starch. 

Excluding bacteria of feces and the ptyalin of the saliva, it would 
seem that the succus entericus and the pancreatic juice were respon- 
sible for the very active diastatic ferment. 

Zweifel and Korwin were unable to extract a diastatic enzyme 
from the pancreas, in infants under three weeks old, and concluded 
therefore that none existed. Their methods cannot be accepted 
at the present time as establishing this point, as the glands were 
macerated and placed in distilled water, in some instances for only 
one-half hour, and then mixed with a strong starch solution. Moro 
followed along the lines laid down by Zweifel by using distilled 
water, though the maceration was continued for a much longer 
time, and in ten infants under three months of age proved a diastase 
in the pancreatic extract in seven. In two of these the infants 
died at birth. One lived fourteen days. Four were between one 
and three months of age. We now know that much stronger ex- 
tracts of the pancreas are to be obtained when the organ is cut into 
small pieces, ground with sand in a mortar, and macerated in a solu- 
tion of 15 percent alcohol or 40 percent glycerin. Furthermore, 
it is not logical to compare with a dead organ the active functionating 
pancreas of a living child under the stimulating influence of food in 
the intestine. Our own observations as to the elaboration of pan- 
creatic extract and the succus entericus have not been carried far 
enough to warrant any authoritative statement based on the findings ; 



FOOD FORMULAS 1 29 

but the claim that the diastase is furnished by the mother's milk is 
negatived to a great extent by the fact that the feces extract from 
meconium stools was as active before breast-feeding as later. 

It will be seen from the foregoing that the majority of infants 
of tender age are able to digest starch. With not every infant is 
this possible, and, according to this report, starchy foods thus resem- 
ble every other substitute feeding. Not every infant by any means 
can take cow's milk or asses' milk or goat's milk; but that starchy 
foods may be added with benefit to infant milk foods in a great 
majority of the cases, and that they may be used with benefit as a 
substitute for these foods in illness, is established beyond all question, 
both experimentally and clinically. 

FOOD FORMULAS 

Beef- juice. — Take a round steak, cut into pieces the size of a 
horse-chestnut, place in a buttered pan in a hot oven, and bake for 
fifteen minutes ; remove from the pan and press out the blood ; add 
salt to the taste. 

Beef, Mutton, and Chicken Broth. — Take one pound of meat 
free from fat, cook for three hours in one quart of water, adding 
water from time to time, so that when the cooking is completed 
there will be one quart of broth. When the broth is cool, remove the 
fat, strain, and add salt to the taste. 

Scraped Beef. — Broil round steak slightly over a brisk fire. 
Split the steak and scrape out the pulp, using a dull knife. 

Egg-water. — The white of one egg, thoroughly beaten in one 
pint of cold, boiled water; strain; add salt to the taste. 

Oatmeal Jelly. — Oatmeal, four ounces ; water, one pint ; boil for 
three hours in a double boiler, water being added, so that when 
the cooking is completed a thin paste will be formed. This while 
hot is forced through a colander to remove the coarser particles. 
When cold, a semisolid mass will be formed. 

Wheat Jelly and Barley Jelly. — Wheat jelly and barley jelly 
are made in the same way as oatmeal jelly, using cracked wheat or 
barley grains. 

Barley-water (No. i). — Robinson's barley flour or Cereo Co.'s 
barley flour, one rounded tablespoonf ul ; water, one pint. Boil 
thirty minutes; strain; add water to make one pint. 

In making Barley-water No. 2, two tablespoonfuls of the flour 
are used. 

Rice-water (No. i). — Rice, one tablespoonful ; water, one pint; 
boil three hours, adding water from time to time, so that there is 
one pint of rice-water at the end of the three hours. 

In making Rice-water No. 2, two tablespoonfuls of rice are used. 

Dextrinized Barley-water. — Robinson's barley flour or Cereo 
barley flour, three tablespoonfuls; water, one pint; boil thirty 
minutes; add water to make a pint. When lukewarm (100° F.), 
9 



I30 



NUTRITION AND GROWTH 



add one teaspoonful of Cereo; strain; this changes the starch into 
dextrinized maltose. 

Oatmeal- water (No. i). — Oatmeal, one tablespoonful ; water, 
one pint; cook three hours and add water to make one pint. 

In making Oatmeal- water No. 2, two tablespoonfuls of oatmeal 
are used. 

Imperial Granum- water (No. i). — Imperial Granum, one table- 
spoonful; water, one pint; cook thirty minutes and add hot water to 
make one pint. 

In making Granum- water No. 2, two tablespoonfuls of Granum 
are used. 

Percentage Gruel Flours. — There has recently been put on the 
market in tin boxes, the covers of which are used as measures, a 
series of flours, especially made for preparing cereal gruels and 
jellies of known percentage composition. On the labels are given 
only the cooking directions for preparing plain or dextrinized gruels, 
and their composition when different quantities of flour are used. 
The V are as follows : 



APPROXIMATE COMPOSITION OF GRUELS MADE FROM CEREO CO.'S 

GRUEL FLOURS. 



Barley. 



Legume. 1 



Oat. 



Wheat. 



c3|. 



^4" ounce flour to quart of 
water 

^ ounce flour to quart of 
water 

^ ounce flour to quart of 
water 

1 ounce flour to quart of 
water 

2 ounces flour to quart of 
water 

3 ounces flour to quart of 
water 

4 ounces flour to quart of 
water 



0.125^ 
0.24^ 
o.M 
0.48^ 
0.96^ 
1.44/0 
1.99/0 



0.60/ 
1.20^ 
1.80/0 
2.405* 
4.80/0 
7.20^ 
9.605^ 



0.19/ 
0.39/0 
0.58/ 
0.78/0 
1.56/ 
2.34/ 
3- 12/0 



1.06/0 

2.12/ 
4.24/0 
6.36/0 



0.24/ 
0.36/0 
0.48/ 
0.96/ 
1.44/0 
1.92/0 



0.60/ 
1.20/ 
1.80/ 
2.40/ 
4.80/ 
7.20/ 
9.60/ 



0.10/ 
0.20/ 
0.30/ 
0.40/ 
0.805^ 
1.20/0 
1.60/0 



0.62/ 
1.25/ 
1.88/ 
2.50/0 
5.00/0 
7-50/ 
10.00/ 



Whey. — Put one pint of fresh milk into a saucepan and heat it 
lukewarm, not over 100° F. ; then add two (2) teaspoonfuls of Fair- 
child's essence of pepsin and stir just enough to mix. Let it stand 
until firmly jellied, then beat with a fork until it is finely divided; 
strain, and the whey, the liquid part, is ready for use. 

Junket. — To one pint of fresh milk add two teaspoonfuls of 
sugar and one junket tablet or two teaspoonfuls of essence of pepsin. 
Allow it to stand over a fire until the temperature is 100° F. ; then 
add vanilla as a flavoring and allow it to stand until the curd is set, 
when it should be placed on ice. 

^ Made from equal parts of peas, beans, and lentils. 



HABITUAL LOSS OF APPKTiTE 13 1 

HABITUAL LOSS OF APPETITE 

The growing child, hke the adult, not only requires sufficient 
nourishment to sustain life, but, in addition to this, an extra amount 
to supply the demands of growth. Proportionate to their size, 
therefore, all growing animals require more food than do those that 
have reached maturity. The young child is naturally such a very 
hungry animal that ample feeding is absolutely essential. Therefore, 
when there is a habitual loss of appetite so that the child's entire 
life may be unfavorably influenced, we must realize the fact that 
the condition is abnormal and strive to discover the cause and 
apply the remedy. 

Physicians are often consulted by parents whose children are 
suffering temporarily or persistently from loss of appetite — a con- 
dition usually associated with secondary anemia and asthenia. 
The child apparently is not ill, he may be active and playful, but 
he tires easily. The sleep ordinarily is sound and refreshing but the 
child must be coaxed to eat. Oftentimes he will take food only 
when his attention is diverted by a story or a toy. He usually eats 
for the entire family, taking a mouthful each for father and mother, 
for the coachman, and for the cook! Three or four times a day, 
depending upon the number of meals, this coaxing, entertaining 
process has to be gone through with. Occasionally in children with 
habitually poor appetites for food in general there will be a history 
of excessive milk- drinking. From three to five glasses of milk may 
be taken daily and all other food refused. When milk forms the 
principal or only article of nourishment after the eighteenth month, 
children will invariably show evidences of malnutrition. They are 
apt to be pale and sallow, with flabby muscles. The most frequent 
cause of loss or lack of appetite is too frequent feeding. It is not 
at all uncommon to see children from two to four 3^ears of age who 
are being fed six or seven times in twenty-four hours, the argument 
of the parents being that: "The child takes so little food, he ought 
to take it oftener." With increasing age, more and stronger food 
is required at less frequent intervals. In other cases children may 
not get their regular feedings at such frequent intervals, but are 
generously supplied between meals with candy, cake, crackers, and 
fruits. Unsuitable food may be the cause of a habitually poor appe- 
tite. Children of tender age who are regularly fed from the adult 
table with heavy adult food, oftentimes improperly cooked, soon 
suffer from loss of appetite. Children who are poor eaters usually 
have the associated ailment, constipation. Too close confinement 
indoors is not infrequently associated with, if not a direct cause of, 
lack of appetite. Children who are kept uninterruptedly in the 
house for weeks at a time invariably have poor appetites. 

Treatment. — In order to emphasize a point in teaching, when treat- 
ment is under consideration, I have sometimes found it useful to state, 



132 NUTRITION AND GROWTH 

first, what not to do. Do not give these children drugs as a means of 
inducing an appetite until all other means have failed. The only 
medication that should be permitted is some simple laxative. There 
must be one evacuation of the bowels daily. The aromatic fluid 
extract of cascara sagrada, from one to two drams, given daily at 
bedtime, or from three to five ounces of the citrate of magnesia 
given before breakfast, ordinarily answers well. 

Fresh Air. — Every "runabout" child should spend at least five 
hours daily in the open air, regardless of the season of the year. 
During very inclement weather in winter indoor airing (see page 
37) is a most satisfactory substitute. 

Diet. — An important step in the treatment is in the regulation of 
the feeding hours. A child from twelve to fifteen months old re- 
quires five feedings daily (see Dietary, page 135). Ordinarily, for 
"runabout" children from the fifteenth to the twenty-fourth month, 
four meals daily are necessary. After the second year, only three 
meals should be given. All feedings should be given at a definite time 
each day, from which there should be no deviation. Nothing what- 
ever except water should be allowed between meals. My next step, 
in case these regulations fail, is to place the child temporarily on a 
markedly reduced diet. No solid food, such as meat, eggs, bread- 
stuffs, vegetables, or fruits, is allowed. The mother m.ust be given 
the directions both orally and in writing. Milk, gruels, and broths 
should comprise the nourishment. 

If the case is one of milk habit, then the milk must be entirely 
cut off, and broth, thin gruel, dry bread, or zwieback substituted. 
The mother is instructed to return with the child in two days. In 
the great majority of instances the report after forty-eight hours is 
that the child is ravenously hungry. When such is the case freer 
feeding is allowed, but under the same strict observance of feeding 
intervals, with absolutely no feeding between meals. It is extremely 
rare to meet a case of habitual loss of appetite which will not respond 
to this simple method of treatment. 

Change of Climate. — Occasionally a child is brought for treatment 
who fails to show the least evidence of disease and yet will not re- 
spond to proper dietetic and hygienic measures. For such, a change 
of climate in addition to proper methods of feeding has been found 
advisable. A change from the city to the country, or from the 
country inland to the seashore, has been followed by a decided 
improvement. When such changes are impossible, or when proper 
dietetic regulations are impracticable, as with our dispensary patients, 
medication may be of service. 

Tonics. — In my experience the best medicinal means of improving 
the appetite is a solution of citrate of iron and quinin in sherry wine, 
one grain of the citrate of iron and quinin being dissolved in one-half 
dram of sherry wine and given, well diluted, before meals. This 
dosage will answer for children over eighteen months of age. For 



COMMON ERRORS IN FEEDING 1 33 

younger children, one -half grain of the citrate of iron and quinin in 
one-half dram of sherry wine, well diluted, may be given. If this 
is not successful one minim of dilute hydrochloric acid, one-half 
minim of the tincture of nux vomica, and two teaspoonfuls of water 
may be given before meals to children over fifteen months and 
under two years of age. After the second year two minims of the 
dilute hydrochloric acid and one minim of nux vomica before meals 
in three teaspoonfuls of water may be given. 

There remain also to be considered under this head not a few 
children who habitually suffer from poor appetite who are below the 
average in every respect. This type of child is considered in detail 
under the heading of The Care of the Delicate Child (page 148). 

COMMON ERRORS IN FEEDING 

In the bottle-fed the most frequent error is overfeeding, or a 
stronger mixture is given than the child is able to digest. Particu- 
larly is this apt to be the case at the commencement of bottle-feeding. 
The amount is usually too large and the intervals between the 
feedings are almost invariably too short. Children of the same 
age cannot all be fed alike. Artificially fed babies of equal health 
and vigor, but of considerably varied size and weight, will require 
food of approximately the same strength and the same intervals 
between feedings ; but the larger the child, the greater the quantity 
of food required. Thus, the quantity given at one feeding for a 
child weighing thirteen pounds at the sixth month will not be suffi- 
cient for a child of the same age weighing sixteen pounds. 

The quantity of food for each feeding for an average baby 
weighing fifteen pounds at six months is about six ounces, and this 
quantity should be diminished one-half ounce for every pound under 
this weight until the total quantity is reduced to four ounces ; and 
for every pound over fifteen, one-half ounce should be added to each 
feeding until the total is increased to nine ounces. The number of 
feedings in twenty-four hours should be the same for all young 
children of the same age. In the table of food formulas given on 
page 103, only the average child of average weight is considered. 

AGE OF CHILD, SIX MONTHS. 
Weight of Child. Quantity for Each Feeding. 

1 1 pounds 4 ounces 

1 2 pounds 4 J ounces 

1 3 pounds 5 ounces 

14 pounds 54 ounces 

1 5 pounds 6 ounces 

16 pounds 6-2" ounces 

1 7 pounds 7 ounces 

1 8 pounds 71 ounces 

1 9 pounds 8 ounces 

20 pounds 8^ ounces 

2 1 pounds 9 ounces 



134 NUTRITION AND GROWTH 

Keeping the child on an exclusive milk diet until he is twelve 
months of age, or older, is a not infrequent error. As a rule, starch in 
some form may be added to the food at the seventh month, and should 
always be added as early as the ninth month. The giving of food 
other than well- cooked cereals and milk before the twelfth month is a 
mistake made in many households, and a common error from the 
twelfth month to the third year is to allow the child's diet to con- 
sist largely of milk and insufficiently cooked cereals. Crackers and 
milk, bread and milk, with cake and fancy crackers, often constitute 
the only articles of diet during this very important period of growth. 
The fact that a high proteid food is as necessary for proper develop- 
ment now as for the bottle age, is overlooked. During early infancy, 
milk answered well, but it is not sufficient for the demands of older 
childhood. Milk, eggs, meat, and cereals, such as oatmeal, rich in 
proteid, are absolutely necessary to normal growth. 

Irregularity in feeding is another frequent error. The child 
should have his meals " ofi the minute," at the same time every day. 
The lack of observance of this rule will surely result in loss of appetite 
and indigestion. Indiscriminate eating between meals, whether 
bread and butter, or pastry, or confectionery, if persistently practised, 
will surely be followed by indigestion and malnutrition. 

Forcing or coaxing a child to eat is a practice always to be 
avoided. If suitable food is given at definite well-ordered intervals, 
a normal child will be hungry at those intervals. If he does not eat, 
something is wrong, and it is our duty to discover the cause of his 
loss of appetite. 

DIET FROM THE FIRST TO THE SIXTH YEAR 

At the completion of the twelfth month the average well-regulated 
baby should be weaned and other nourishment given. If bottle- 
fed, he should receive more than the milk and cereals, with which 
most children are fed. The food suitable for the second year of life 
and the method of its preparation and administration are subjects 
upon which the masses are most profoundly ignorant. A few children 
at this period of Hfe are underfed, but the great majority are overfed, 
and carelessly given, at improper intervals, unsuitable food, wretch- 
edly cooked. Summer diarrhea finds its greatest number of victims 
among those children over twelve months of age who have been care- 
lessly fed. 

The Second Summer. — The dreaded ;' second summer" robs 
many homes because of ignorant or careless parents. The second 
summer, managed properly, is hardly more dangerous than any other 
summer during the early ^^ears of a child's Hfe. It is almost an uni- 
versal custom when the child is weaned or given something other 
than a milk diet, to allow him " tastes" from the table. Very often 
these tastes comprise the entire dietary of the adult. Milk is often- 
times the only suitable article of diet that is given. Afterward not 



DIET FROM THE FIRST TO THE SIXTH YEAR 1 35 

only is the other food selected unsuitable, but it is given irregularly, 
and supplemented by crackers kept on hand for use between meals. 
During the hot months the gastro-intestinal tract is less able to bear 
such abuse and the child becomes ill. 

Feeding After the First Year. — Usually when the twelfth month 
is completed I give the mother a diet schedule, with instructions to 
begin gradually with the articles allowed, in order to test the child's 
ability to digest them. Every new article of food should be carefully 
prepared and given at first in very small quantities. All meals are 
to be given regularly, with nothing between meals. With many 
children this expansion of the diet-list is attended with considerable 
difficulty. They are thoroughly satisfied with milk and refuse all 
other forms of nourishment. In such cases time and patience are 
necessary at the feeding-time. The more solid articles of diet should 
be given first and the milk kept in the background. 

Among the underfed seen at this period of life are those who were 
nursed too long or those who were kept too long upon an exclusive 
milk diet. A great majority of the cases of malnutrition of the second 
year are seen in the exclusively milk fed. They are pale, soft, flabby, 
badly nourished children. 

The following is a diet schedule which I have employed for several 
years. Each mother is instructed to select, from the foods allowed, 
a suitable meal: 

From the twelfth to the fifteenth month; five meals daily: 
7 A. M. Oatmeal, barley or wheat jelly, one to two tablespoon- 
fuls, in eight ounces of milk. (The jelly is made by cooking the 
cereal for three hours the day before it is wanted and straining through 
a colander.) Stale bread and butter or zwieback and butter. 

9 A. M. The juice of one orange. 

1 1 A. M. Scraped rare beef, one to three teaspoonfuls, mixed with 
an equal quantity of bread and moistened with beef-juice. Or a soft- 
boiled egg mixed with stale bread-crumbs ; a piece of zwieback and a 
half-pint of milk. 

(Scraped beef is best obtained from round steak, cut thick and 
broiled over a brisk fire sufficiently to sear the outside. The steak 
is then split with a sharp knife and the pulp scraped from the fiber.) 

3 p. M. Beef, chicken, or mutton broth, with rice or stale bread 
broken into the broth. Six ounces of milk, if wanted. Stale bread 
and butter or zwieback and butter. Many children at the above age 
will take and digest apple-sauce and prune pulp ; when these are given 
milk should be omitted. 

6 p. M. Two tablespoonfuls of cereal jelly in eight ounces of 
milk; a piece of zwieback. Stale bread and butter or Huntley and 
Palmer breakfast biscuit. 

10 p. M. A tablespoonful of cereal jelly in eight ounces of milk. 



136 NUTRITION AND GROWTH 

From the fifteenth to the eighteenth month; four ineals daily: 

7 A. M. Oatmeal, hominy, cornmeal, each cooked three hours 
the day before they are used. When the cooking is completed the 
cereal should be of the consistency of a thin paste. This is strained 
through a colander, which upon cooling will form a mass of jelly-like 
consistency. Of this give two or three tablespoonfuls, served with 
milk and sugar, or butter and sugar, or butter and salt. Eight to 
ten ounces of milk as a drink. Zwieback or toast. 

9 A. M. The juice of one orange. 

II A. M. A soft-boiled ^gg mixed with stale bread-crumbs, or 
one tablespoonful of scraped beef (page 129), mixed with stale bread- 
crumbs and moistened with beef-juice. A drink of milk. Zwieback 
or bran biscuit, or stale bread and butter. 

3 p. M. Mutton, chicken, or beef broth, with rice or with stale 
bread broken in the broth. Custard, cornstarch, plain rice pudding, 
junket, stewed prunes, baked apple, or apple-sauce. 

6 p. M. Farina, cream of wheat, wheatena (cooked two hours). 
Give from one to three tablespoonfuls, served with milk and sugar, 
or butter and sugar, or salt and butter. Drink of milk. Zwieback 
or stale bread and butter. 

From the eighteenth to the twenty -fourth month; four meals daily: 

7 A. M. Cornmeal, oatmeal, hominy (prepared as in the above 
schedule). Serve with butter and sugar, or milk and sugar, or butter 
and salt. A soft-boiled &gg every two or three days. Hashed chicken 
on toast occasionally. A drink of milk. Bran biscuit and butter 
or stale bread and butter. 

9 A. M. The juice of one orange. 

1 1 A. M. Rare beef, minced or scraped, the heart of a lamb chop, 
finely cut. Chicken. Spinach, asparagus tips, squash, strained 
stewed tomatoes, stewed carrots, mashed cauliflower. Baked apple 
or apple-sauce. A drink of milk. Stale bread and butter. 

After the twenty-first month baked potato and well-cooked string 
beans may be given. 

3 p. M. Chicken, beef, or mutton broth, with rice or with stale 
bread broken into the broth. Custard, cornstarch, or plain rice pud- 
ding, junket, stewed prunes. A drink of milk. Bran biscuit and 
butter or stale bread and butter. 

6 p. M. Farina, cream of wheat, wheatena (each cooked two 
hours). Give from one to three tablespoonfuls, served with milk and 
sugar, or butter and sugar, or butter and salt. Drink of milk. 
Zwieback or stale bread and butter. 

From the second to the third year; three meals daily: 
Breakfast: 7 to 8 o'clock. Oatmeal, hominy, cracked wheat 
(each cooked three hours the day before they are used) , served with 



DIET FROM THE FIRST TO THE SIXTH YEAR 1 37 

milk and sugar or butter and sugar. A soft-boiled egg, lamb chop, 
hashed chicken. Stale bread and butter. Bran biscuit and butter. 
A drink of milk. 

At ten o'clock the juice of one orange may be given. 

Dinner: 12 o'clock. Strained soups and broths, rare beefsteak, 
rare roast beef, poultry, fish. Baked potato, peas, string beans, squash, 
mashed cauliflower, mashed peas, strained stewed tomatoes, stewed 
carrots, spinach, asparagus tips. Bread and butter. A glass of 
milk. For dessert: Plain rice pudding, plain bread pudding, stewed 
prunes, baked or stewed apple, junket, custard, or cornstarch. 

Supper: 5.30 to 6 o'clock. Farina, cream of wheat, wheatena 
(each cooked two hours). Give from one to three tablespoonfuls 
serv'ed with milk and sugar, or butter and sugar, or butter and salt. 
Drink of milk. Zwieback or stale bread and butter. Twice a week, 
custard or cornstarch, or jtmket may be given, or a tablespoonful of 
plain vanilla ice-cream. 

As a rule, three meals answer best at this period. With three 
meals a child has a better appetite and much better digestion, and 
consequently thrives far better than one whose stomach is kept con- 
stantly at work. Some children, however, will require a luncheon 
at 3 or 3.30 p. M., and will not do well without it. This is apt to be the 
case with delicate children, particularly those under two and one-half 
years of age. If food is necessary at this hour, a glass of milk and 
a Graham biscuit or a cup of broth and zwieback will answer every 
purpose. Instead of the afternoon meal, the child may rehsh a 
scraped raw apple or a pear. Fruit at this time is particularly 
to be advised if there is constipation. Children recovering from 
serious illness will require more frequent feeding. 

From the third to the sixth year: 

Breakfast: Cracked wheat, cornmeal, hominy, oatmeal (each 
cooked three hours the day before they are used). These may be 
served with milk and sugar, or butter and sugar, or butter and salt. 
A soft-boiled egg, omelet, scrambled egg, chop. Bread and butter, 
bran biscuit and butter. A glass of milk. 

Dinner: Plain soups, rare roast beef, beefsteak, poultry, fish, 
potatoes stewed with milk or baked. Peas, string beans, strained 
stewed tomatoes, stewed carrots, squash, boiled onions, mashed cauli- 
flower, spinach, asparagus tips, bread and butter. For dessert: Rice 
pudding, plain bread pudding, custard, tapioca pudding, stewed 
prunes, stewed apples, baked apples, raw apples, pears, and cherries. 

Slipper: Farina, cream of wheat, wheatena (each cooked two 
hours). Give from two to three tablespoonfuls, served with milk and 
sugar, or butter and sugar, or butter and salt. Zwieback or stale 
bread and butter. Bread and milk. Milk toast. Scrambled eggs 
twice a week. Custard or cornstarch each once a week, ice-cream 
once a week. Bread and butter. A glass of milk. 



138 ' NUTRITION AND GROWTH 

When the child has eggs for breakfast, they should not be repeated 
in any form for supper. Red meat should be given but once a day. 
When the child has a chop for breakfast, he should have poultry or 
fish for dinner. At this age of great activity and rapid growth, the 
child will often demand food between dinner and supper. Carefully 
selected fruit, such as an apple, a pear, or a peach, may be given at 
this time, supplemented by a Graham cracker or two, or by stale 
bread and butter, if it is found that their use does not interfere with 
the evening meal. 

DIET AFTER THE SIXTH YEAR 

When the normal child has passed the sixth year the diet may 
be considerably expanded, approximating to that of the adult in 
variety; certain restrictions, however, are to be borne in mind. 
Fried foods should not be given, highly seasoned dishes, such as pie, 
rich puddings, gravies, and sauces, are to be avoided. Salads with 
plain dressing may now be given. Wine and beer, coffee, and tea 
should never be given to children as a beverage. A point to be 
kept in mind in feeding children of this age, as well as those who 
are younger, is the proper cooking of vegetables. Everything in 
the line of green vegetables should be cooked until it can readily be 
mashed with a fork. 

HO"W THE CHILD SHOULD BE FED 

In the foregoing articles on feeding I have endeavored to explain 
the nature of the food required by the growing child, and the inter- 
vals at which food should be given. This, however, does not entirely 
cover the subject. A child should never dine with adults until he 
can have adult diet, if the circumstances of the family permit him 
to dine alone or with other children. It is a refinement of cruelty 
to expect a hungry child of tender age to sit at the table, see and 
smell the fragrant dishes, and be forced to content himself without 
complaint with his restricted fare. I recall this custom as a cause of 
many tears, disputes, and fistic encounters with attendants, which 
formed no small part of the daily routine of my own early life. 

In feeding, the spoon or fork must come in contact only with the 
food and the child's mouth. If it falls to the floor by accident it 
should be dipped into boiling water before using it. Under no 
circumstances should a feeding utensil be allowed to come in contact 
with the lips of the nurse or mother. Time and again I have seen 
mothers and nurses sip or swallow the first teaspoonful of the food 
which is to be given, to determine if it is of the proper temperature, 
using the spoon to feed the child immediately thereafter. At other 
times, when the food is not particularly attractive to the child, she 
will place the spoon in her own mouth as though intending to take 
it herself. Or she will remove from the spoon, with her own lips 
adhering particles of food. There are few more reprehensible prac- 



DIET DURING ILLNESS 1 39 

tices than the foregoing, and if parents knew the dangers to which 
their children were thus subjected they would not for one instant 
tolerate them. Any one of the many forms of pathogenic bacteria 
may thus be readily transferred to the mouth of the child. It 
is unquestionably a means of infection with tuberculosis, diphtheria, 
and syphilis. The germs of tuberculosis and diphtheria are fre- 
quently found in the mouths of perfectly healthy adults. They 
cause no symptoms of disease because of the normal power of resis- 
tance of such adults. The resisting powers of the child, however, 
to these microorganisms are very slight, and when these germs are 
carried to the delicate mucous membrane of the infant's mouth and 
throat they thrive actively, the child develops diphtheria or tuber- 
culosis, and the family grieves and wonders how the child could ever 
have contracted the disease. 

DIET DURING ILLNESS 

The digestive capacity of every child is diminished during illness, 
the extent depending largely upon the age of the child and the sever- 
ity of the disease. The younger the child, the greater the incapacitv. 
This is fairly constant with all the ailments of childhood, including, 
of course, those which directly affect the gastro-enteric tract. 

Reduction in Food Strength. — In a moderately severe bronchitis, 
with a degree or two of fever, the digestive capacity is slightly dimin- 
ished and a 25 percent reduction in the strength of the food will 
answer. During the critical stage of a lobar pneumonia the digestive 
powers are held in abeyance and predigested foods and alcohol must 
sustain the patient. During an attack of measles, scarlet fever, bron- 
chopneumonia, or diphtheria in bottle-fed infants, at the height of the 
disease, it is my custom to reduce the strength of the food one-half by 
the addition of water, to make up for the quantity removed. For ail- 
ments of lesser severity, such as bronchitis, with a temperature of 100° 
to 101° F., or chicken-pox, or mild measles, I reduce the strength of the 
food from one-fourth to one-third. In any mild ailment or injury 
which confines a child to its bed, the food strength should be cut 
down, for inactivity as well as disease lessens the digestive capacity. 

Among nurslings and the bottle-fed these precautions are partic- 
iilarl}^ necessary. A child with fever is apt to be thirsty and to take 
more food than in health. This is frequently the case in summer 
diarrhea. In order to avoid this taking too much food, I not only 
order the milk to be diluted for the bottle-fed, but I instruct the 
mothers of nurslings to give a drink of wafer immediately before each 
nursing and between nursings, and then to allow the child to nurse 
only one-half or two-thirds the usual time. For the bottle-fed, one- 
half to one-third the contents of each bottle is removed and the 
quantitv replaced by boiled water, so that the amount of fluid given 
remains the same. 

If a child is a "runabout," over two years of age, he is given broths 



140 NUTRITION AND GROWTH 

and thin gruel — one-half milk and one -half gruel. By carefully watch- 
ing the stools, thus fitting the food to the child's capacity, we will 
avoid grave intestinal complications which, during the summer, often 
prove to be more serious than the original ailment. In the acute gastro- 
enteric troubles, and in typhoid fever, all milk must be discontinued. 

The dietetic management of the acute intestinal diseases and 
typhoid fever is referred to in detail under their respective headings. 

The Art of Feeding in Illness. — Not only is food oftentimes taken 
in insufficient quantity in illness, but in many cases it is absolutely 
refused. In other cases, during coma and asthenic states, swallowing 
is impossible. In delirium and in conditions of collapse nourish- 
ment must be given, and when this is impossible by the natural 
method, we have, as temporary substitutes, gavage, oil inunctions, 
and rectal feeding — all referred to elsewhere. 

Forcing the child to take nourishment by the mouth is rarely 
necessary. Coaxing and bribing ordinarily succeed far better. 
For a child from three to five years of age a bright new penny pos- 
sesses much persuasive power. The child will usually take its food 
better from those to whom it is accustomed, like the mother or 
nursery maid. The trained nurse should understand that while 
unacquainted with the patient, the simpler requirements of the 
child are to be looked after by others to whom the patient is accus- 
tomed. 

The nourishment should be as palatable as possible and served 
in bowls, cups, or plates that are attractive to the patient, be- 
cause of color, pictures, or peculiarities of shape. Junket, flavored 
with vanilla, served cold is a favorite food for sick children of the 
"runabout" age. Frozen custard and home-made ice-cream, made 
with one-third cream and two- thirds milk, will usually be well taken. 
Toast, dry bread, and crackers made in peculiar shapes are attractive 
to the child. In not a few cases I have succeeded in feeding satis- 
factorily children two or three years old, when several other schemes 
had failed, by allowing the temporary return to the bottle, from 
which they had been weaned for a year or so. 

In these difficult feeding cases the child's peculiarities and wishes 
must be studied. Children in illness require water. Oftentimes 
they take it in insufficient quantities. Those who refuse plain 
water will often take ginger ale, sarsaparilla, or vichy. In the event 
of these drinks being well taken, they may be given freely. In the 
acute infectious diseases, w^hich include pneumonia, free water- 
drinking is a therapeutic measure of no mean value. 

GAVAGE 

Gavage, or forced feeding, is the introduction of nourishment 
into a child's stomach by means of a tube (Fig. 16). The tubes 
are to be obtained at the instrument-makers and are known as 



GAVAGE 



141 



" stomach-tubes for children," or the physician can make one himself 
at a small cost. All that is required is a soft-rubber catheter, 
American No. 12, a one-eighth inch glass tube two inches long, two 
feet of one-quarter inch plain rubber tubing, and a small glass funnel. 
An extra opening should be cut in the catheter about one-half inch 
from the original one. This allows a more rapid introduction of 
the nourishment. The opening can very easily be made with a 
small pair of curved scissors. 

In Obstinate Vomiting. — Gavage, or forced feeding, will be found 
useful in three types of cases. First, as a means of feeding in obsti- 
nate vomiting. Several years ago, when the writer was resident 
physician at the New York 
Infant Asylum, a series of 
observations were made on 
cases of persistent vomiting 
which could not be con- 
trolled by stomach-washing 
or the ordinary means of 
treatment. It was found 
that patients who could not 
retain a tea spoonful of 
water when administered 
by a spoon or a bottle would 
retain from one-half ounce 
to one ounce of water when 
given through a tube. The 
same child who vomited 
one teaspoonful of milk 
or other food would re- 
tain this amount and a 
great deal more when the 
food was given b}^ the 
tube. This discovery led 
to more extended obser\"a- 
tions. Twenty cases of 
persistent vomiting in all 
were treated in this way, 
of which eighteen were re- 
lieved. This series of ob- 
servations was the first made relating to the use of gavage or forced 
feeding in persistent vomiting.^ 

The tube which is to be passed into the stomach should never be 
oiled, but merelv dipped into the solution that is to be used. It is 
then passed in rapidly with the funnel empty and the nourishment 

^ Kerley: "Gavage in Persistent Vomiting in Infants," Archives of Pediat- 
rics, Feb., 1 89 1. 




Fig. 16. — Stomach-tube. 



142 



NUTRITION AND GROWTH 



immediately poured into the funnel. When the food has passed 
into the stomach, the tube should be compressed and quickly with- 
drawn. Some of the liquid retained in the tube, if it is not compressed, 
may escape into the larynx and cause choking, coughing, and perhaps 
vomiting. The food selected should be thin dextrinized gruels, or 
broths and gruels combined, which have answered well in some cases. 
When used for the obstinate vomiting cases, it is well to use gavage 
only once every four or six hours, with from one-third to one-half 





Fig. 17.— Fkeding by Gavage. 



the quantity of food given in health. In a severe illness, such as 
diphtheria, pneumonia, and the grave intestinal diseases, gavage 
may save the life of the patient. Not infrequently, in such cases, 
insufficient nourishment is taken to support life. Rectal feeding 
is usually of value only for a day or two, as children soon become 
intolerant of it. In such circumstances, gavage may be employed 
adva.ntageously for several days at a time. In fact, it is the only way 
by which the child can be properly nourished. 



GAVAGE 143 

I 

The position of the child for gavage may be the same as for 
stomach-washing, or the child may rest on his back (Fig. 17). It is 
well to clear out the stomach with warm water before each feeding. 
In children without teeth the bare index-finger is all that is necessary 
to keep the mouth open. In children with teeth the Denhard gag 
of the O'Dwyer intubation set (page 325) should be used. Pre- 
digested cereal foods, completely peptonized milk, and stimulants 
well diluted may be given. Usually these patients badly need water. 
If there is no tendency to vomiting, a large quantity of water may 
be given with the nourishment selected, so that they may get as 
much liquid as they are accustomed to in health. Gavage is also 
most useful in cases of extreme malnutrition and exhaustion or in 
those under alcohol or opium narcosis. Infants suffering from an 
extreme degree of malnutrition and exhaustion are often admitted 
into a hospital; and occasionally they are seen in private practice. 
The children are so reduced in strength that not enough energy 
remains for the taking of nourishment. In these cases gavage is 
distinctly a life-saving measure. The food should be predigested 
cereals, peptonized milk, or one of the various peptone preparations, 
given in quantities suitable to the age of the child. For a child four 
months of age, from two to four ounces of peptonized milk may be 
given every two hours. Before the next feeding it is well to intro- 
duce a few ounces of water and withdraw^ it to see if the food has been 
properly digested. By this means of feeding there will be noticed, 
if the vitality is not at too low an ebb at the commencement, a daily 
increase in strength and vigor, which proves that the powers of 
assimilation persist after the desire for food or the child's ability to 
swallow it has passed. This proves that we must never regard such 
a case as hopeless so long as the child is breathing. Time and again, 
after a few days' feeding in this way, the child will take the food from 
the bottle or spoon. Breast-milk, if it can be obtained, may be 
given by gavage as successfully as can predigested cow's milk. 
The malted foods on the market have been used temporarily with 
advantage, for, while deficient in nutritive value for the well, they 
afford sufficient nourishment for temporary use in the very ill, and 
are easy of digestion. 

Illustrative Case. — In a recent case seen in consultation, the pa- 
tient, three months old, was almost moribund, as the result of ex- 
treme malnutrition. The temperature ranged from 94° F. to 96° F. 
for several days. No food could be taken. A wet-nurse was secured, 
but the child would not nurse. He was pale, apathetic, and too weak 
to cry. The wet-nurse's milk was drawn from the breast and spoon- 
feeding attempted, but swallowing was impossible. One and one-half 
ounces of breast-milk were fed by gavage, but this proved too strong, 
and the child promptly vomited it. It was then diluted one-half 
with weak barley-water. At first one ounce was given at a feeding. 



144 NUTRITION AND GROWTH 

which was gradually increased to two ounces, all being retained and 
digested. In a week the child was able to nurse, and made a com- 
plete recovery, weighing, when seven months of age, fourteen pounds. 
At the time gavage was commenced, it weighed but five pounds. 

SUBSTITUTES FOR STOMACH-FEEDING 

In the management of the diseases of children conditions arise 
from time to time which necessitate the nourishment of the patient 
by channels other than the stomach. In persistent vomiting, when 
there is an acute involvement of the stomach, as in an acute gastro- 
enteric infection, or when the vomiting is due to some more 
remote cause, as in meningitis or nephritis, or where the attack is 
one of cyclic vomiting. In short wha ever be the cause, the patient 
must receive water and food in order to sustain the system until 
the exciting factor is removed. 

Nutrition by means other than the stomach may be necessary 
in retropharyngeal adenitis or abscess, in stricture of the esophagus, 
in diphtheria, in the exanthemata, and in pneumonia during the 
course of active delirium. A substitute for stomach-feeding is often 
useful in marasmus, in the generally delicate, and in those with 
reduced assimilative powers. Various means of substitute feeding 
have been attempted from time to time. Nutritive suppositories 
have been advocated and proved failures, perhaps because of our 
inability to place them sufficiently high in the bowel. Placed in the 
rectum, they excite peristalsis and are expelled. 

Hypodermic Feeding. — Hypodermic feeding, and the introduction 
of food into the circulation, in children are unsafe and impracticable. 

Feeding by Inunction. — Feeding by means of oil inunctions, by 
active friction, or by the more passive means of wrapping the 
child in oil-soaked cotton and allowing him to rest in it, is thought 
by many to be effective, in spite of the fact that the skin is an organ 
of excretion, and that its powers of absorption are very slight. I 
am convinced that, for infants and young children, the inunctions of 
properly selected oils possess distinct nutritive value, more benefit 
being derived by the patient than can be attributed to the lubrication 
of the skin and the massage. The rubbing of mercurial ointment into 
the skin is one of the most familiar means of introducing mercury 
into the circulation. No one will dispute the efficacy of this form 
of treatment. Fat inunctions are useful in marantic infants, and in 
delicate "runabouts" with low, fat-digestive capacity. In chronic 
diseases also, such as tuberculosis, syphilis, and rheumatism, oil 
inunctions are of advantage. They may be used with service during 
convalescence from the severe acute diseases which have not only 
reduced the patient's weight, but have so affected the digestive and 
assimilative functions that a return to health is materially retarded. 
A brine bath (page 31) should precede the inunctions, both of 



SUBSTITUTES FOR STOMACH-FEEDING I45 

which are best given at bedtime. If possible, an animal fat should 
be used. Goose oil and unsalted lard are preferred. Cod-liver oil 
is never advised on account of its very disagreeable odor. Olive 
oil may be employed in case the unsalted lard or goose oil is not 
obtainable. Cacao-butter is the least desirable of all fats that may 
be used for this purpose, particularly if the child is young and 
athreptic, for the reason that there may not be enough bodily heat 
to keep the oil fluid after it has been rubbed into the intercellular 
spaces and hair-follicles. For children under one year of age, it is 
my custom to direct that one-half ounce of goose oil, unsalted lard, 
or olive oil be rubbed into the skin of the arms, thorax, legs, and 
back immediately following the salt bath. The rubbing is to be 
continued until the oil disappears, which may require from ten to 
fifteen minutes. The rubbing should be done with the palm of the 
hand and not with a brush or a cloth. In a few children it is difficult 
to have the oil absorbed, even though not more than one dram is 
used. This usually occurs in those who most need the oil — athrep- 
tics with low temperature, in whom the superficial circulation is very 
poor. After the inunction the child should at once be put to bed. 
For older children, one-half to one and a half ounces of the oil may 
be used. It will soon be learned how much will be required for the 
ten to fifteen minutes' rubbing. In these older children, also, the 
inunction should follow the brine bath. The use of the oil inunction 
in hundreds of cases has proved its efiicacy. How much of the 
beneficial eft'ects are due to the oil as a food ; how much to the mas- 
sage, producing better skin action, improving the nutrition of muscles 
and inducing better sleep, I am unable to say. The beneficial 
effects of the inunction are probably due to three factors : The oil 
acts to a slight extent as a food, the massage increases the functional 
actiA^ty of the skin and improves the muscle nutrition. 

Rectal and Colonic Feeding. — Any means of treatment which 
is disagreeable both to patients and attendants, and difficult of 
execution, is very liable to fall into disfavor unless pronounced 
beneficial results are the rule. While absolutely nothing can be 
promised so far as supplying nutrition by this means is concerned, 
careful obserA^ation and experience tell us that in a certain number 
of cases it is a measure of much value. AA^hen the treatment will be 
of service in nourishing the patient can be determined by trial only. 
In children, particularly in very young children, on account of the 
ease with which peristalsis is excited, nutrition by this means is 
less frequently successful than in the adult. Nevertheless it has 
been of material assistance to me in man}' a trying situation. Not 
a few of the failures are due to a lack of appreciation as to the details 
of the procedure. Directions to mothers or nurses to inject a 
certain quantity of some particular food, unless specific instructions 
are given, will usually be carried out as follows: A hard glass or 



146 NUTRITION AND GROWTH 

rubber tip will be passed into the rectum from one to two inches. 
Through this the fluid is forced. In a very few minutes, perhaps 
immediately, the bowel empties itself into the napkin or bed-pan, 
the enema being of no service. This is what may be expected and 
what will happen when the child is given the nutrient enema in this 
way. The hard tip placed within the anal ring and the fluid are 
very apt to excite vigorous peristalsis. In order to have the nour- 
ishment retained, it should be carried high up into the descending 
colon. The advantages of this method are two : It is much better 
retained, and, on account of the greater surface of mucous membrane 
with which it comes in contact, it will be quickly and more com- 
pletely absorbed. 

How to Give a Nutrient Enema. — The nutrient enema is best given 
as follows : A soft-rubber catheter. No. 18 American, or a small rectal 
tube, adult size, is used, the former being preferred. The catheter 
or tube is slipped over the small tip of an ordinary fountain syringe. 
The tube should not be too flexible nor yet too stiff. If too flexible, 







Fig. 18.— Hard-rubber Piston Syringe. 

it folds readily on itself when the point meets with any resistance, 
and the fluid escapes perhaps an inch or two within the anal open- 
ing. If the tube is too rigid or if force is employed, the mucous 
membrane and the parts may very easily be lacerated. 

The position of the child while the enema is being given is impor- 
tant. He should rest on his left side, preferably in Sims' position, 
with the buttocks elevated to a plane at least four inches higher 
than the shoulders. A pillow or a folded blanket covered with a 
rubber sheet should always be available for this purpose if a bed-pan 
is not at hand. The child, if old enough to understand, is assured 
that no harm will come to him. With the patient in position and 
an assistant to hold him, the anus is covered with vaselin. It is 
not enough to oil the tube. The tube attached to a fountain syringe 
is warmed and well oiled and passed into the rectum. The lower 
end of the bag should be three feet higher than the child's body. 
There may be some straining at first, but with the child in a proper 
position and a tube of the right degree of flexibility, it requires but 
a few seconds to pass it high into the intestine. At least nine inches 
should be introduced, sufficient, at least, to enable it t9 be felt in the 
descending colon when the fluid is allowed to pass rapidly into the 



SUBSTITUTES FOR STOMACH-FEEDING 1 47 

bowel. When the bag is emptied, the tube is rapidly withdrawn 
and the child, although allowed to change to the dorsal position, 
is encouraged to rest on his side. In any event, the buttocks must 
be kept elevated for at least one-half hour. In using small amounts 
of fluid it is well to allow for the quantity which may remain in the 
tube of the syringe and in the catheter after the enema is given. 
In older children, in whom there is much bearing-down or straining, 
it may be necessary to attach the catheter to a Davidson syringe 
or to an ordinary rubber (Fig. i8) or glass piston- syringe of large 
size, in order to provide sufficient force to overcome the pressure 
exerted by the abdominal muscles. 

The nutriment should be neither too hot nor too cold. With 
either of these extremes, peristalsis is apt to be excited. I have 
found a temperature of 95° F. to be the most satisfactory. If bowel 
action has been fairly free, previous washing with a normal salt solu- 
tion is not necessary. If there has been no movement in six hours, it 
will be well first to use an irrigation of normal salt solution. Gly- 
cerin should not be used. The irrigation should precede the enema 
by from fifteen minutes to half an hour. 

Nourishment Not to be Used in the Rectum. — Do not use oils or 
fats in any form, even though pancreatinized. Alcohol should be 
used only in very urgent cases, and then it should be well diluted 
and used not oftener than once or twice in twenty-four hours. It 
has a decidedly irritant action on the intestinal mucous membrane 
and is not well retained. When used, it should be diluted with 
from twelve to sixteen parts of water or an equal quantity of skimmed 
milk, which has been peptonized or pancreatinized. In giving stimu- 
lants by the rectum, whisky is usually employed in quantities 
from one -fourth ounce for a child two years of age, to one ounce for 
a child from six to ten years of age. 

Nourishment to he Used. — By far the best food for rectal alimen- 
tation is skimmed milk completely pancreatinized. It is better re- 
tained and more completely assimilated than is any other means of 
nutrition which we possess, as shown by its results in maintaining the 
nutrition and strength of the patient. In cases in which it is desired 
that a considerable amount of fluid be absorbed by the intestine, the 
pancreatinized milk may be diluted with a normal salt solution. 
Where such milk is not available, the whites of three raw eggs, mixed 
with a normal salt solution, may be given. Not infrequently I order 
the whites of one or two raw eggs given in the pancreatinized 
skimmed milk. I believe this combination gives us the best form of 
nutrient enema. The predigested proprietary preparations, the so- 
called "peptones," have not been satisfactory in my hands. 

Illustrative Case. — In a recent severe case of cyclic vomiting, which 
was seen in consultation, the vomiting had persisted for three days. 



148 NUTRITION AND GROWTH 

This child was six years of age. There was marked emaciation, with 
a weak, soft pulse and intense thirst. A nutrient enema was given 
composed of eight ounces of skimmed milk, pancreatinized, eight 
ounces of normal salt solution, and the whites of two eggs. Not 
one drop was expelled. In one-half hour the boy claimed to feel 
better. The intense thirst was relieved and he fell into a restful 
sleep. In six hours the enema was repeated, about four ounces being 
expelled. This was followed by enemata at eight-hour intervals, 
eight ounces of the milk with the whites of two eggs being given, 
all of which was retained. At this point the vomiting abruptly 
ceased and further enemata were not required. 

The amount of nourishment to be used at one time varies with the 
age and condition of the child. 

ORDINARY AMOUNT TO BE GIVEN IN ENEMA 

Under 3 months 2-4 ounces 

From 3 to 6 months 4-6 ounces 

From 6 to 24 months 6-8 ounces 

After the 24tli month 8-16 ounces 

Because the first enema is not retained, it does not follow that 
a second given immediately thereafter will share the same fate. 
In not a few instances I have given the second enema ten minutes 
after all or the greater part of the first had been expelled, and the 
entire amount of the latter was retained. It is rarely wise to repeat 
the enema oftener than at six-hour intervals; and, when the intestine 
shows a tendency to intolerance, the intervals should be increased 
to eight or ten hours. 

This means of nutrition in children is but for temporary use at 
best. The period of its application in the average case, even when 
tolerated at first, is only two or three days. In a few instances I 
have been able to use it longer than this. During the summer of 
1903 a very delicate three-months-old child under my care, weighing 
six pounds and ten ounces, retained two ounces of completely 
pancreatinized skimmed milk, given at six-hour intervals for three 
days, and three ounces at eight-hour intervals for eight da3^s longer, 
making a period of eleven days in which the enemata were employed. 
Such tolerance of the large intestine is very rare, however. 

In another case the use of enemata following an operation for 
intestinal obstruction with protracted vomiting and prostration 
unquestionably saved a child's life. 

THE DELICATE CHILD 
In pediatric practice one frequently meets with children who, 
while they cannot be said to be suffering from any disease or path- 
ologic condition, yet are inferior in physical development, lack 
endurance, and possess poor resisting powers. They are usually 
under height, always under weight, and, in short, have so many 



THE DELICATE CHILD 1 49 

characteristics in common that they constitute a class themselves, 
and as such warrant our attention. 

Normal Development. — The average child, at the various periods 
of early life, conforms with a certain degree of regularity to the mental 
and physical development which by long association we have come to 
regard as normal. Thus a standard may be said to have been estab- 
lished, and it is up to this standard that we expect the growing child 
to measure. This is what we look upon as the average of physical 
and mental development. A few children exceed these requirements ; 
they are stronger and larger at the sixth month than the average 
child at the ninth month. Again, older children at the fourth or fifth 
year are in every way equal to their normal playmates a year or 
two older. 

Abnormal Development. — On the other hand, there are children 
who are born with a reduced vitality, or who, through faulty manage- 
ment, usually in relation to feeding, acquire a reduced vitality. 
Semi-invalid adults almost invariably beget semi-invalid children. 
If the parents are of average health and of good habits, and the de- 
bilitated condition of the child is due to faulty management and 
nutritional errors, the result of proper dietetic and hygienic manage- 
ment is usually prompt and satisfactory. With the persistently deli- 
cate, the offspring of physically enfeebled parents, the results are 
less satisfactory. 

Treatment. — By proper regulation of the habits of a delicate 
child, however, as regards all the details of his daily life, a far better 
adult is produced than if no such effort had been made. In other 
words, a diet and general regime of life best adapted to the individual 
in question will invariably improve the physical condition of that in- 
dividual. This applies to the strong as well as to the delicate, to 
the growth and development of the young of the lower animals as 
well as to the offspring of man. It is the poorly developed, delicate 
child that we are particularly to consider — the undersized, frail, 
small-boned, under-weight child, whose appetite is persistently poor 
or capricious, who sleeps poorly, tires easily, is usually constipated, 
who is subject to catarrhal conditions of the respiratory tract, and 
whose powers of resistance generally are diminished. 

On assuming the management of one of these children it is 
absolutely necessary to make a thorough examination, followed 
in some instances by a few weeks' observation, in order to become 
acquainted with the case in its individual aspects, to learn idiosyn- 
crasies, and to eliminate the factor of actual disease as a causative 
agent. When we demonstrate to our satisfaction that the child 
is free from such diseases as tuberculosis, syphilis, and malaria; 
when we have eliminated by properly directed treatment all causes, 
such as adenoids, phimosis, adherent clitoris, vaginitis, or parasitic 
and irritant skin lesions, which may have had a deterrent influence 



150 NUTRITION AND GROWTH 

Upon growth; and when we have satisfied ourselves as to the actual 
condition of our patient, we are in a position to lay down definite 
rules of management. 

Every child has a distinct function to perform. As soon as he 
is born he is confronted with a serious problem — the problem of 
growth, physical and mental. Inasmuch as this growth and develop- 
ment depend, above all things, upon a properly adapted food-supply, 
it must be our first step to provide such nutriment as will be most con- 
ducive to it. As growth takes place in all parts of the body through 
cellular activity, the nutritive elements which support cell prolifera- 
tion must be important constituents of the diet, and among these 
the proteids are of prime importance ; hence in the management of 
these children a point to be remembered in the adaptation of the food 
is the necessity of feeding as rich a proteid as the child can assimi- 
late. The younger the child, the greater the necessity for growth. 

Regular Weighings Necessary. — An infant should be weighed at 
regular intervals, and if under one year of age, should not be con- 
sidered as doing even passably well if not gaining at least four ounces 
weekly. When a baby remains stationary in weight its development 
is invariably abnormal. When stationary or when only a slight gain 
of one or two ounces weekly is made, we will always find after 
a few wrecks that there is malnutrition, in spite of the apparent 
gain, as will be evidenced by the symptoms of beginning rickets — 
anemia, the characteristic bone changes, flabby muscles, and a 
tendency to disease of the mucous membranes. Delicate infants 
should be weighed daily at first; then, as improvement takes place, 
at intervals of two or more days, but never less frequently than once 
a week, if under one year of age, no matter how vigorous they may 
become. The weighing keeps us directly in touch with the child's 
condition, but since the increase may be in fat alone, an occasional 
examination of the child stripped is necessary to tell us whether 
there is substantial growth in bone and muscle. 

Feeding Infants. — ^When it is demonstrated that a child will not 
thrive on the breast of the mother, another breast should be substi- 
tuted, or an adapted high-proteid cow's milk should form the diet in 
part or in whole. If the child is bottle-fed and it is demonstrated 
that proper growth and development are impossible on cow's milk, 
on account of proteid incapacity, then a wet-nurse should be secured. 

When, after the first year, more liberal feeding is allowed, the 
necessity for a high proteid in the food selected is as urgent as before. 
This applies to those children who are brought to us showing evi- 
dences of late malnutrition, as well as to those whom we have had 
under our care from early infancy. 

An important element in the diet up to the third year is milk. 
A child from the first to the third year ought to receive one quart of 
milk daily. Unfortunately, many debilitated children have a very 



THE DELICATE CHILD 15I 

poor capacit}' for fat assimilation. When given full milk in as 
small an amount as one pint daily, they often develop foul breath, 
coated tongue, and loss of appetite, or they suffer from frequent 
attacks of acute indigestion. The milk is necessary, not because 
of the fat, which can easily be dispensed with, but because of the 
high percentage of proteid which it contains — from 3 to 4 percent. 
When this fat incapacity exists, the milk is said to "disagree," but 
skimmed milk will be taken without inconvenience. Enough sugar 
may be added to bring the percentage up to seven, in order that it 
may replace the fat, for fuel. Skimmed milk with sugar added 
furnishes a food of no mean order. Too much milk, however, 
must not be given. When large quantities, more than one quart 
daily, are taken, the desire for more substantial nourishment, such 
as eggs, meat, and cereals, is removed. 

At the completion of the first year, keeping in mind a high 
proteid (page 93), begin with scraped beef, at first one teaspoonful 
once a day, in addition to the cereal and milk. If this is well borne, 
and it usually is, a teaspoonful may be given twice a day, and later 
three times a day. It may be given immediately before the bottle- 
feeding. Eggs should be brought into use from the twelfth to the 
fifteenth month. At first one-hah an egg, boiled two minutes, is given 
mixed with bread-crumbs. If well borne, a whole egg may be 
allowed. The cereals used should be those most rich in vegetable 
protein, such as oatmeal, containing 16 percent of proteid, dried 
peas, 20 percent of proteid, and dried beans, containing 24 percent 
of proteid. The peas, beans, and lentils should be given in the 
form of a puree. 

Diet after the First Year. — If the child during the second year has 
an indifferent appetite, reduce the quantity of milk; never allow 
more than one pint of skimmed milk daily for the first week or 
two. ^lany delicate children who apply for treatment after the first 
vear of age have been subjected to as grave errors in diet as are seen 
among the bottle-fed. Starch and milk oftentimes furnish the only 
means of nutrition up to the fourth or fifth year, the starch used 
being generallv in the form of bread, crackers, and ill-cooked cereals. 
In one case four quarts of milk were taken daily by a boy of seven 
years. 

It will be seen that it is our aim in this class of children — the 
delicate, undersized, slow-growing class — to give as liberal a nitro- 
genous nourishment as is compatible with the digestive capacity 
of the patient. But if the child has had rheumatism, or if there is 
a tendency to lithiasis, the use of a large amount of meat is con- 
traindicated. It is in such children that the high-proteid cereals 
are particularly valuable. In a general way, from early life the 
diet of the delicate child should consist of milk, suitably adapted, 
with highly nitrogenous cereals added, w^hen permissible. ^lany 



152 NUTRITION AND GROWTH 

delicate children of the "runabout" age who cannot digest milk 
containing 4 percent of fat will easily digest butter fat when spread 
on bread or potatoes. In this way I often use it to supply fuel to 
act as a proteid-sparer. Oatmeal-water, or oatmeal jelly, mixed 
with the milk should be ordered at the seventh month. When age 
allows, the addition of raw or rare meat, poultry, eggs, and purees of 
dried peas, beans, and lentils should be given. Boxed, "ready to 
serve" cereals are never given; raw cereals are used, which are cooked 
three hours. While a high-proteid diet is desirable, other things 
are necessary. Green vegetables, animal fats, the ordinary cereals, 
cooked and raw fruits, are required to furnish the necessary acids 
and salts, as well as the necessary variety. In short, the ideal diet 
for a delicate child is that combination of foods which, while imposing 
the least burden upon the digestive organs, supplies the body with 
material exactly sufficient for its needs, and such a food must be 
rich in nitrogen. (See dietary, page 134.) 

Baths. — On account of the fear that a delicate child may take cold, 
the bath is often omitted. Every child, both the well and the deli- 
cate, after the second week should be tubbed daily. The delicate 
particularly require it. The salt bath (page 31) is usually advised. 
The best time for giving the bath is at bedtime, and in order to 
avoid all chance of exposure the temperature of the room should be 
elevated to 80° F. The temperature of the water may vary. It 
should never be above 95° F. except for very delicate young children 
in whom there is a tendency to a subnormal temperature. Even 
in these cases the temperature of the bath should never be higher 
than the temperature of the body. In the frail and in the very 
young the bath should not be continued over five minutes. In 
older children, those of eighteen months or over, if the physical 
conditions allow, a distinct advantage will be gained by a reduction 
of the temperature of the bath while the child is in the water. An 
immersion in water at 90° F. , followed by a gradual reduction during 
the space of five or six minutes to 70° F., should, upon brisk rubbing, 
be followed by a quick reaction. For children after the third year, 
a graduated cold spinal douche has served me well. (See Spinal 
Douche, page 29.) If the reaction is not good, if the extremities 
are cold and are slow in becoming warm, the reduction in the tem- 
perature should be less or none at all. In the very poorly nourished, 
a reduction below 80° F. should not be attempted. Following the 
drying process, primarily for the benefit of the massage, goose oil or 
olive oil should be rubbed into the skin over the entire body for from 
five to ten minutes. The bath and the massage inunction, besides 
favorably influencing nutrition, are a very effective means of inducing 
sleep. 

Fresh Air. — Delicate children are usually deprived of a proper 
amount of fresh air, for the same reason that they are insufficiently 



THE DELICATE CHILD 153 

bathed — the fear of making them ill. All children need an abundance 
of fresh air, both in illness and in health. The robust and the delicate 
require it, and to the delicate it is much more essential than to the 
robust. As many hours daily as practicable should be spent out of 
doors. The time thus spent depends upon the season of the year 
and the residence of the child, whether in the city or the country. 
In the city, during the colder months with pleasant weather, the 
child should spend at least five hours daily in the open air, dividing 
the day into two outing periods — from 9 to 11.30 in the morning and 
from 2 to 4.30 in the afternoon. On very cold days, 20° F. or below, 
on stormy days, and on days with very high winds, the child is 
given his airing indoors. He is dressed as for out of doors, placed 
in his carriage, and left in a room, the windows on one side of the 
room being open. Not infrequently during February and March 
delicate children will be prevented from going out of doors for 
several consecutive days. If some means for a daily systematic 
indoor airing is not provided, these children will often go backward, 
no matter how excellent the other management. The first symptoms 
are loss of appetite and the ability to assimilate the food. In my 
private work among athreptics, the child is placed in the baby- 
carriage or in a basket and allowed to rest before an open window 
for ten or twelve hours of every twenty-four, with a hot-water 
bottle at his feet. Here he is fed, being removed only temporarily 
to warmer quarters for a change of napkins. I have three roof- 
gardens in operation. A boy patient nine months of age has been 
in the street only once in four months, then only in going to church 
to be baptized. 

Sleep. — The delicate child requires no more sleep than does the 
strong, and the rules governing this matter at the various periods 
of life are the same both for the strong and for the weak. (See 
Sleep, page 27.) The sleeping-room of the delicate child should 
always communicate with the open air by a window, either directly 
or through an adjoining room. A satisfactory method of ventila- 
tion is by the window-board (page 44). The child should occupy 
the room alone, if possible, sharing it neither with an adult nor 
another child. This applies to all ages, but is particularly necessary 
after the second year. 

The Nursery. — The temperature of the nursery, day or night, 
should never be above 70° F., during the colder months, and in the 
very young, or in those who are difficult to keep covered, it should 
not go below 65° F. at night. 

Delicate children of the "runabout" age are very susceptible 
to colds. In the management of such children it is necessary to use 
every precaution against exposure. The most frequent way of 
exposing a child to cold is by allowing him to sit on the floor. To 
keep the child of from ten months to three years of age off the floor 



154 NUTRITION AND GROWTH 

during the winter months, and thereby to eHminate this means of 
exposure, is a very difficult matter. In fact, with active children 
learning to walk, or who have just learned to walk, it is practically 
impossible under the usual conditions. During the colder months 
there is always a current of cold air near the floor, and allowing the 
child to creep in winter, even if the floor is protected by rugs and 
carpets, is one of the surest ways of permitting him to take cold. 
If he is allowed to walk on the floor he is soon very sure to sit down. 
If he is not allowed to creep and walk about at will, he will not get 
the proper exercise and will show faulty development. For such 
cases, I have found the exercise pen of immense service (see Fig. 4). 
After being dressed, washed, and fed, the child is placed in the pen, 
on a rug if desired. Toys are given him and the door is closed. He 
can now roam about at will, stand up, sit down, creep or walk without 
the slightest danger from drafts. 

Influence of Climate. — Much has been written regarding the influ- 
ence of climate in the type of case we are considering. According to 
my observation, this matter does not deserve the attention it has re- 
ceived. The city child in a well-to-do family is, as a rule, better off 
for eight months of the year in his own home with its usual conveni- 
ences. The benefits attributed to change in climate are usually the 
result of a change not of climate but to more fresh air, which is af- 
forded by the larger rooms of the hotel, with its loosely constructed 
doors and windows ; and since the parent is desirous that the child 
shall receive the full benefit of the change, he is kept in the open air 
for a much longer time than when at home. The air at such a place 
is more expensive, and consequently more appreciated than the air 
at home. With sufficient heat and proper ventilation, we may make 
our own climate. It is not to be denied, however, that a change of 
residence for a few weeks from New York to Lakewood or Atlantic 
City during March and April is sometimes of advantage. 

From the first of June to the first of October the dehcate child 
should not remain in New York city. The humidity and the heat 
which may prevail for protracted periods during this time render it 
unsafe, particularly during July and August. The seashore for the 
entire summer is not to be advised. The children whom I have sent 
inland to the country and to the mountain have, as a rule, returned 
in the autumn in a much better physical condition than those who 
spent the summer by the sea. 

Clothing. — Thin, poorly nourished children require more clothing 
than do those physically normal. A fairly good index as to whether 
a child is sufficiently clad is the condition of his lower extremities. 
The forearm and hand cannot be relied upon. The legs and feet of 
every child should always be warm to the touch. 

As to the nature of the clothing: A mixture of silk and wool 
next to the skin is most desirable. As a second choice a mixture of 



THE DELICATE CHILD 155 

wool and cotton is used. The linen mesh, often useful in the vigo- 
rous "runabout," is not to be advised in the delicate. 

Exercise. — Moderate exercise is to be encouraged. But it should 
never be allowed to the point of fatigue. In large cities all delicate 
" runabouts" from three to five years of age should be allowed to walk 
not more than six blocks in going to the playgrounds. If the distance 
is greater, the child should ride part of the way, play or walk for a 
time, and then be placed in the carriage or cart and ride home. 
Younger children, two or three years of age, should be wheeled both 
ways and taken out at the park for a run when the weather con- 
ditions permit. 

Midday Nap. — Every day after the midday meal the child, regard- 
less of age, whether two years or six, should be undressed and put 
to bed for two hours. He should be left alone in the room, and 
whether he sleeps or not he should remain in bed for the two hours. 

Entertainment. — Entertaining play is necessary, but every kind of 
excitement, such as children's parties, emotional plays at the theater, 
and rough play with older children, should be avoided. 

Education. — The delicate child under eight years of age should be 
taught only to the extent of strict obedience and good habits. Other 
than this he should be a little animal. There should be no teaching 
in the ordinary sense of the term, no mental stimulation, until the 
child is physically able to bear it. When school-work begins, which 
in this class of children should never be before the eighth year, the 
studies should be made easy and the school-hours short. Such chil- 
dren should never be crowded. I usually direct that they attend 
only the morning session. 

The delicate child should be carefully watched from the time it 
comes into our hands until it reaches the normal oi until the period 
of development is completed. While the scheme of management 
as outlined will not always be attended with brilliant results, it 
will not be in vain. Many lives will be saved, and as a result of 
the increased acquired resistance, stronger men and women will be 
added to the race than would otherwise have been possible. 

Now and then I meet with a case among the well-to-do in which, 
because of prolonged faulty feeding or vicious heredity, the vital 
spark is so low that, fan it as we may, no impression is made upon it. 
As a rule, these stubborn cases are the offspring of alcoholism and 
debauchery. They are thin, anemic infants; they develop into thin, 
anemic children, and into thin, anemic adults. The delicate and 
degenerate are found in all the walks of life, but they are especially 
numerous in dispensaries and in children's institutions. 

Much of the work of the pediatrist is with the weakly of the so- 
called "better class." His success in the management of these 
delicate children depends largely upon the home cooperation, and a 
promise of this he should obtain before taking the case. The 



156 NUTRITION AND GROWTH 

parents must be taught that the development of the intellect, the 
character, and the body go hand in hand, and that a vigorous intel- 
lect is rarely found without a vigorous body. It is impressed upon 
them that the body is more than a machine. It has delicate organs 
to hold, to keep in repair and supply with energy. It has a nervous 
organization; it has sensibilities. The normal exercise of all these 
functions demands the normal nourishment of the body. In my 
experience, family cooperation in a few instances has been difficult to 
obtain. The parents began well, but soon tired of the extra work 
required. The care of the young has always been undertaken in such 
a wretched, unscientific manner that it is difficult to make the un- 
trained mind appreciate the necessity of careful attention to details 
in his management. 

The Child vs. the Animal. — It is a startling fact that 75 percent of 
all children do not get as scientific care and attention, as regards the 
selection of food, housing, and exercise, as do the calves and colts, the 
lambs and pigs, of any high-class stock-farm. Is this because the child 
has no market value in dollars and cents ? In France, during the past 
few years, this defect in the people as a whole has received govern- 
mental attention; and on account of the diminished birth-rate, the 
value of a human life is beginning to be appreciated. That the subject 
of better care of the young deserves our earnest consideration is well 
illustrated by the statement recently made in the House of Commons, 
by Sir William Anson, Parliamentary Secretary of the Board of Edu- 
cators, that sixty thousand children of those attending the London 
schools were physically unfit for instruction. The Adjutant-General 
of the EngHsh Army Medical Service reported that one man in every 
three offered as recruits ought to be rejected. 

MARASMUS; ATHREPSIA; INFANTILE ATROPHY 
Under this title will be considered those cases of marasmus 
which are associated with and dependent upon derangement of 
function of the gastro-enteric tract. Tuberculosis, syphilis, and 
atelectasis are consequently excluded, these affections being con- 
sidered elsewhere under their respective headings. 

Marasmus is seen most frequently in young infants under nine 
months of age. Cases are frequently seen, however, from the ninth 
to the twelfth month, and comparatively few between the twelfth and 
eighteenth months. A great deal of research work has been done 
in marasmic infants in order to determine the nature of the condition, 
but as yet no satisfactory explanation has been offered. The disease 
is unquestionably due to defective intestinal assimilation. The 
principal fact that disproves the existence of any atrophic condition 
or any necessarily severe derangement of function is that these cases 
very often make complete recoveries, becoming perfectly normal 
children after three months or more of treatment. 



marasmus; athrepsia; infantile atrophy 157 

The story of these cases, which we have heard hundreds of times, 
both in out-patient and in private work, is about as follows: The 
mother could not or did not nurse the baby. The child was put on 
cow's milk, which was usually given too strong or in too large 
quantities — oftentimes both errors were combined, or the milk may 
have been too old when used and improperly cared for; in any 
case the milk disagreed, the child was made ill, there was loss in 
weight, cow's milk was discontinued, and one of the infant foods, 
alone or combined with milk, was given; but, the child's digestion 
being thoroughly disordered, the foods failed to agree. There was 
vomiting or regurgitation with undigested green stools, or both 
combined, while the loss in weight continued. The child may have 
been inherently weak or there may have been a cow's-milk idiosyn- 
crasy to help account for the lack of success in the milk-feeding. 
Usually there followed a series of experiments with different kinds 
of food and methods of feeding, the vomiting, diarrhea, or colic 
continued with wasting, and when the child reached the dispensary 
or office he was perhaps six months of age and weighed from six to 
nine pounds, presenting a typical athreptic picture. Some of these 
children are born with a digestion that is apparently incompatible 
with cow's-milk mixtures. Others have their digestive capacity for 
cow's milk hopelessly deranged by improper feeding methods. The 
majority of the cases occur among the overcrowded tenement 
poor — the worst possible environment for a delicate infant. There 
is little or no proteid assimilation, so that any approximation to 
normal growth is impossible. They may also possess a poor fat 
capacity, and if there is also a diminished sugar capacity the proteids 
of the tissues are drawn upon to supply heat and energy, with 
resulting progressive emaciation. Heredity, environment, and the 
season of the year, all influence the prognosis. 

Treatment. — An important determining factor, however, as to the 
child's future, depends upon whether or not he can have the advantage 
of a wet-nurse. That a great majority of the cases of simple athrepsia 
recover, and often recover promptly, making a most satisfactory 
growth, when a wet-nurse is secured, is proof, as above stated, that 
the condition depends more upon the nature of the nutrition than 
upon the patient, so far as relates to any peculiar systemic state or 
pathologic condition. In securing a wet-nurse the physician's duties 
are by no means completed. The patient may not take kindly to 
the breast and he will have to be taught breast-nursing. A great 
deal of time may be required in teaching older infants, those who 
have been on the bottle for seven or eight months. To this end, 
various devices may have to be used. For the first nursing it is 
well to allow the child to go for an hour or two beyond the feeding- 
time in order that his appetite may be voracious. It is advisable 
also to give the first few nursings in a darkened room with the 



158 NUTRITION AND GROWTH 

person who has been accustomed to feeding the patient very near. 
Sufficient milk should be forced from the breast to enable the child 
to taste it. A little powdered sugar sprinkled on the nipple is a good 
means of increasing his interest. In some instances it has been 
necessary to cover the wet-nurse with a blanket or sheet, leaving 
only the breasts exposed ; or it may be necessary to use the nipple- 
shield (Fig. 8) for a few days in order gradually to accustom the 
child to the change. I have yet to see a case in which success did 
not follow persistent effort. Oftentimes the nurse's milk will not 
agree at first; but this is not surprising and need cause no dis- 
couragement. Breast-milk ordinarily is a much stronger food 
than the child has been accustomed to, and it may produce vomit- 
ing or colic or diarrhea. When indigestion follows, the nurse's 
milk should be modified by giving the baby weak barley-water or 
plain boiled water before the nursing, in case he nurses well, or after 
the nursing in case he nurses poorly. One or two ounces of breast- 
milk at a feeding is all that these patients can be expected to take 
during the first few days. The amount obtained may readily be 
determined by weighing the patient, without the trouble of undressing 
him, before the nursing, and then weighing him at intervals of from 
three to five minutes after the nursing has commenced. An ounce 
of breast-milk is practically an ounce avoirdupois. These children, 
if they are not too weak, will take greedily almost anything from the 
bottle. The addition of an ounce or two of barley-water or plain 
water dilutes the milk and renders it easier of digestion, and furnishes 
at the same time the necessary fluid for the child. The most unprom- 
ising cases of marasmus are not to be despaired of nor the treatment 
relaxed, although the physician should be cautious in his prognosis. 
Hospitals and institutions for children always carry a certain number 
of these cases. It is not infrequent to find miliary tuberculosis at 
autopsy where it was not suspected during life, no clinical signs of 
fever having been present. If the child is too weak or indifferent to 
swallow, the wet-nurse's milk may be expressed, diluted, and given by 
gavage. I have in a few instances peptonized the wet-nurse's milk. 

Illustrative Case. — The most pronounced and the most hope- 
less recovery case coming under my observation was seen by me 
in consultation in one of the suburbs of New York. The child 
was four months old and weighed five pounds. He was ema- 
ciated to a skeleton, having weighed eight pounds at birth. The 
temperature for several days ranged between 92° and 94° F. A 
trained nurse and an unusually intelligent mother were in charge. 
I doubted the accuracy of the thermometer reading, and different 
thermometers were used. The temperature was taken by the rec- 
tum. I took the temperature myself on one or two occasions with 
my own thermometer and found the reading correct. The attending 
physician had also taken it repeatedly, so that there was no doubt 
as to the matter. The child was too weak to nurse. The breasts 



marasmus; athrepsia; infantile atrophy 159 

were accordingly pumped, and for each feeding he was given one-half 
ounce of breast-milk with an ounce of barley-water, to which a few 
drops of sherry wine were added. This was given by gavage at 
two-hour inter\^als. He was wrapped in flannel and wool and sur- 
rounded with hot- water bottles. The food was retained and digested. 
In four days he could nurse, and was allowed to take a small amount 
from the breast and finish the meal with barley-water. The tem- 
perature gradually rose to the normal, ^lore breast-milk was 
allowed as he proved able to care for it, and the child made a perfect 
recovery, weighing eighteen pounds when he was nine months old. 

This case demonstrated to me that a marasmic child is never a 
hopeless case until he ceases to live. Unfortunately very few 
marantic children can have the benefit of a wet-nurse, but without 
her the majority of these cases are hopeless. I have seen such cases 
take their modified milk or whatever was given them without 
inconvenience. The stools may be offensive if cow's milk is given, or 
there may be constipation or the stools may appear perfectly normal. 
As a rule, there is no serious diarrhea or any other evidence of an 
acute inflammatory process in the intestine. However, in spite of 
fairly normal stools, the patient grows thinner and thinner. After 
a time all food is refused, gavage is used as a last resort, and the 
child finally dies. The autopsy shows nothing but pale organs with 
perhaps a strip of hypostatic pneumonia. Xow and then one of 
these cases in a children's institution or in a hospital recovers without 
a wet-nurse, but it is the exception proving the rule. Put these 
athreptics on a wet-nurse, as I do at every opportunity, and many 
of them thrive in spite of the well-known unfavorable infl.uence 
exerted by institutional life upon the very young. In addition to 
putting the athreptic baby on the wet-nurse, his stomach should be 
washed once daily and he should live out of doors. 

Outdoor Life. — Next to the wet-nurse, I know of no measure 
fraught with so much good as is outdoor life. The season of the year 
exerts considerable influence on the prognosis. The athreptic bears 
the heat and humidity very badly, and the early summer mortality of 
all large cities is materially increased by these children, who wilt and 
die in institutions and tenements with the first two or three days of 
continuous hot weather. Parents of such children residing in a large 
city who can afford it, should send them to the country not later than 
June ist, to return, in this latitude (New York city), not earlier than 
October ist. During the day the child should be on a porch or in the 
shade continuously. At night the windows of his sleeping-room 
should be wide open. During the colder months if the child is too ill 
to be taken out of doors he should have from morning until evening 
a continuous indoor airing (page 37), and the sleeping-room should 
always communicate with the open air. The roof-garden in large 
cities is a most valuable aid in the management of athreptic children. 

Tenement Cases. — ^^^'hile much has ahead v been said about this 



l6o NUTRITION AND GROWTH 

most interesting and important subject, one phase of it has not been 
touched upon. I refer to the athreptic infant of the tenement, and 
those others in private Hfe for whom a wet-nurse is impossible. They 
furnish by far the largest number of our marasmic patients. Perhaps 
the most frequent error in the management of these cases is an en- 
deavor to select at the start a food for the child to thrive upon. In 
doing this, almost invariably a stronger food is selected than the child 
is capable of digesting, and he is made worse by the attempt. Our 
ultimate object in these infants will be more readily attained if, at 
first, we attempt only to supply the child with a food upon which he 
can exist without loss in weight. The number of calories necessary 
for an athreptic child is not great. It must be remembered, further- 
more, that we are not dealing with a case of infant-feeding as the 
term is commonly understood. True, we are feeding an infant, but a 
sick infant, and the methods of feeding used in the comparatively well 
do not apply here in all respects. The problem of nourishing these 
children is to be considered from two standpoints — that of the food and 
that of the baby, with special reference to his organs of digestion. 
The stomach, in many of these infants, is dilated, with a consequent 
lack of motility. Residual undigested food remains long after feed- 
ing. There has been a constant fermentative change, with the pro- 
duction of lactic and butyric acids, resulting in local changes of an 
inflammatory nature in the mucous membrane of the stomach, so 
that not only must the organ be prepared for the food, but the food 
must be adapted to the stomach capacity, and when this is done, when 
both receive due consideration, we are much more likely to succeed. 

Stomach-washing . — In all of these cases, for the first few days 
of treatment, I wash out the stomach with sterile water, regard- 
less of the presence of vomiting and regurgitation and regardless 
as to whether the child is bottle-fed or breast-fed. It is often sur- 
prising to note the amount of thick mucus and undigested food that 
will be washed from a stomach from which there has never been 
vomiting. The daily washings enable the child to take more food 
and stronger food. It may be necessary to continue the washings 
for days. They may first be discontinued when the water siphons 
clear and without mucus. They should be repeated if there are 
indications calling for it, such as regurgitation of sour water or 
mucus or a loss of appetite. In a case seen recently in which there 
was chronic gastritis with athrepsia, washings were continued at 
gradually lengthened intervals for six months. 

Feeding. — If the case is one with pronounced stomach involve- 
ment, a 3 percent milk-sugar solution is given for twenty-four hours 
in quantity suitable for the age and size of the patient. The follow- 
ing day barley-water No. i is given, to which sugar is added to make 
the mixture 5 percent. 

Cow's Milk. — While it is doubtful if the child can take cow's 
milk after this period of stomach-rest and stomach-washing, it may 



marasmus; athrepsia; infantile atrophy i6i 

b2 attempted. Two drams of as safe milk as can be obtained 
is added to every second feeding of the barley-and-sugar water. 
If it agrees, after a day or two, two drams are added to each feeding, 
with a gradual increase of a dram every two or three days. The 
intervals of feeding, for children under one year of age, may range 
at from two to three hours. It is rarely advisable to feed even the 
most delicate athreptic oftener than once in two hours. If the milk 
can be retained and assimilated in the strength of one-fourth milk and 
three-fourths barley with 5 percent sugar, or if an equal quantity 
of milk and sugar- water alone is found to agree, the child will begin to 
grow and general improvement will follow rapidly. If the cow's milk 
is not well borne, skimmed milk (page 96) , or a weak cream mixture 
— one-half dram of cream to a feeding — maybe tried. It is practically 
impossible to have whey made properly outside of a hospital labora- 
tory or an intelligent home. In using whey it may be given in quan- 
tities suitable to the age of the patient. The prescribing of cream 
among the poor is a hazardous procedure for these infants. It may 
be old, improperly cared for, and swarming with bacteria. If there 
is a tendency to looseness of the bowels the diarrhea is thus made 
worse. Cream mixtures rarely succeed as foods for athreptic chil- 
dren. I use it only among those who can properly care for it. 

Condensed Milk. — I have found that in the out-patient athreptic 
the much-abused condensed milk fulfils a useful function. It is 
the cleanest food we can give the dispensary baby. It is the cheapest, 
the most easily kept, and the most easily digested milk that can be 
furnished him. Consequently when cow's-milk feeding is imprac- 
ticable or when it disagrees, I give condensed milk, beginning with 
one-half dram, which is added to the barley-water or to the plain 
water for every second feeding, later to every feeding, increasing the 
quantity gradually as the child shows an ability to digest it. The 
patient must be seen frequently and the stools carefully examined 
in order that an increase in the food strength may be made as soon as 
conditions allow. The mother is told to bring the napkins to the 
dispensary, the child is weighed at each visit, every second day, 
and it is most gratifying to see how well some of them gain in weight, 
not because they are getting an ideal food by any means, but because 
it fits the case, temporarily. Condensed milk is thus used as a 
stepping-stone to something better. When the child has taken it with 
benefit for a month or six weeks, cow's milk is attempted if the time 
of the year is between October and the following June . After June i st 
I would continue with condensed milk, as a baby showing some degree 
of anemia and rachitis as the cooler months approach is to be pre- 
ferred to the risk of attempting cow's-milk feeding, with poor milk, 
in the hands of overworked or ignorant mothers. 

In beginning cow's milk, in order to avoid sudden radical changes I 
replace one feeding of the condensed-milk mixture daily with one feed- 



1 62 NUTRITION AND GROWTH 

ing of a weak cow's-milk mixture. In some cases this will produce 
illness and must be stopped; in others, it will be well borne. When 
it is found to agree, two feedings should replace two condensed- 
milk feedings daily. In this way, by increasing by one the number 
of cow's-milk feedings every third or fourth day, entire cow's-milk 
feeding may safely be inaugurated. The strength of the cow's milk 
should not, of course, correspond to that suggested for well babies. 
For a child of six months a three-months' formula may be given. 
As the child improves, the strength of the milk may correspondingly 
be increased. In this way I have treated successfully a great many 
tenement athreptics. 

Some children will be able to take and properly care for only 
two cow's-milk feedings daily; others will take every second feed- 
ing of cow's milk. I have a patient at the present time aged four- 
teen months. He will take two cow's-milk feedings daily with com- 
fort, but when the third is given he is invariably made ill. Some 
will not be able to take a particle of cow's milk. When this is the 
case, the condensed milk should be combined with a gruel, such as 
oatmeal, which contains a high percentage of proteid. These cases 
may also be given beef -juice at a very early age. I often use pure 
cod-liver oil, from fifteen to thirty drops, which is usually taken three 
times daily without disturbance. The tenement athrepfic is given 
the benefit of as much fresh air as possible. He is also given the 
advantage of the daily tub-bath and the oil rub. 

MALNUTRITION IN INFANTS 

I am often asked by students the difference between malnutrition 
and marasmus in infants. While hard and fast lines cannot be drawn 
as to where malnutrition ends and marasmus begins, there is a vast 
difference between the two conditions. Malnutrition may best be 
described as the first stage of marasmus. Every child with marasmus 
must first have undergone a longer or shorter period of malnutrition. 
In malnutrition the infant is under- weight, his gain being slow and 
irregular, the muscles are soft, and if the condition persists, bone 
changes, indicatmg rachitis, appear. Malnutrition may be the 
result of faulty digestion and assimilation engrafted upon faulty 
feeding, often combined with overfeeding. The patient shows 
evidence of indigestion in a distended abdomen and in stools that 
are far from the normal, or there may be no intestinal derangement 
whatever, the malnutrition being due to the fact that the child's 
diet for months had consisted of food that did not contain the 
nutritional elements required. Infants who subsist for a considerable 
length of time on a diet of condensed milk or the malted infant foods, 
without cow's milk, almost invariably show signs of general malnu- 
trition. 

A case due to high-fat feeding was recently seen by me. The 
patient was a male, six months of age, weighing thirteen pounds, 



MALNUTRITION IN INFANTS 1 63 

resident of a New York suburb where the conditions are most 
healthful. His fontanel was slightly depressed, the muscles were 
soft and flabby, the ribs beaded, and the child had lost his appetite 
and suffered from constipation. A history of the feeding showed 
that he had been getting a cow's-milk mixture containing approx- 
imately 6 percent fat, 4 percent sugar, and 2 percent proteid. In 
this patient the indigestion, loss of appetite, and constipation 
were unquestionably due to the high percentage of fat. The energy 
exerted in digesting the food almost counterbalanced the benefit 
derived from it, the result being a very slow gain in weight. 

Treatment. — Diet. — The management of malnutrition due to such 
causes consists in correcting the digestive errors, in using castor oil or 
calomel with stomach-washing, and in adjusting the food to the child's 
requirements and digestive capacity, always remembering that a child 
who should have from 3 to 4 percent of fat cannot be expected to 
thrive on i percent, as is the case when condensed milk is given; nor 
can he be expected to thrive when the use of a 6 percent cow's-milk 
fat mixture is long continued. Likewise very low proteid or very high 
proteid will be followed by malnutrition, the one producing indiges- 
tion and interference with the assimilative powers, the other supply- 
ing too little nutrition to the organism. In either event, the child 
does not get the nutrition required. The amount of proteid given in 
condensed milk is rarely above 0.5 percent. The proprietary meal 
foods and condensed milk mentioned elsewhere are useful in certain 
types of illness and in convalescence from illness. They must not, 
however, be selected as the sole articles of diet. A mistake fre- 
quently made in the feeding of these cases is to give the food at too 
frequent intervals. At the sixth month three-hour feedings, six 
in twenty-four hours, are best, even though the food is weak. The 
stomach will bear stronger food sooner when given at longer intervals 
than it will when given at interv^als of two and one -half hours. 
When the child is nine or ten months of age, four-hour intervals 
usually answer best. In the underweight and delicate it may be 
necessary to continue with the three-hour feedings after the sixth 
month. Cow's milk should be the basis of the diet, given according 
to the suggestion in the section on Marasmus. In many cases cereal 
gruels made from barley or oatmeal may be added with advantage. 
Malt soup (page 109) may often be used with success in these patients. 
A milk formula below that indicated by the child's age may have to 
be given for a long time. Thus, when six months of age he may be 
able to take but a three-months' formula; when nine months of age, 
a six months' formula. I have constantly under my care infants 
who cannot take cow's-milk mixtures corresponding in strength to 
that usually taken by well infants of the same age. 

Hygiene. — Attention to the matter of outdoor life, indoor airing on 
inclement days, and residence in the country during the heated term 
is of great importance in the general management. During the 



1 64 NUTRITION AND GROWTH 

cooler months the child should receive inunctions of unsalted lard 
or goose oil after the daily evening bath. Constipation, if present, 
is treated by the oil injection method (see page 185), or olive oil may 
be given by the mouth, one to two drams after two or more feedings 
each day. Besides being of decided benefit in relieving the consti- 
pation, it adds not a little to the nutrition of the patient. 

TARDY MALNUTRITION 

Malnutrition with tuberculosis and syphilis is not a part of our 
subject. In the sections on Malnutrition in Infants and Children 
it may be thought by some that there is repetition of what is said 
under the title of The Delicate Child. While the management neces- 
sarily is along the same lines, two distinct types of children are 
represented. The marasmic and malnutrition infant or young child 
may be but temporarily delicate. When the simple malnutrition 
case recovers it may develop into as normal a specimen of robust 
childhood as could be desired. The delicate child as I have endeav- 
ored to describe him is inherently delicate, and our efforts are toward 
improving his condition, with the hope perhaps, but with no great 
assurance, that he will some time become a robust adult. Tardy 
malnutrition is seen in children of the school-age. They are deficient 
in weight, in resistance to disease, and in capacity for work; they 
are pale, thin, tired children. 

Etiology. — Cases of tardy malnutrition as well as those of maras- 
mus and infantile malnutrition are seen in all the walks of life, 
among the wealthy, the so-called middle class, and among the poor. 
Strange as it may seem, these cases, regardless of the station in life, 
have one cause common to all — defective feeding. The scion of 
wealth who is overfed, or badly fed — given food which is unsuitable, 
and allowed the promiscuous use of sweets — may develop malnutri- 
tion just as effectively as the child of the tenement who subsists on 
fried meats, grocery milk, boxed breakfast foods, and other nonde- 
script products of the bakery around the corner. There is a painful 
lack of knowledge among all classes as regards the nourishment re- 
quired by a growing child. He is fed to satisfy his appetite, and 
when this is accomplished the parents believe that their duty is 
done. How far they fall short of proper feeding is demonstrated 
daily in out-patient clinics and in private work. Poverty is an oc- 
casional cause of bad feeding in New York City. 

Treatment. — -I have repeatedly seen children from five to ten years 
of age with marked malnutrition gain from three to five pounds the 
first month under treatment which consisted simply in giving food 
that they had a right to demand, properly prepared at definite inter- 
vals. The school-child suffering from malnutrition should be re- 
moved from school temporarily and as much outdoor life as possible 
should be enjoyed by him, regardless of his station in life. Every- 
thing of a strenuous nature should be avoided. He should be put to 



TARDY MALNUTRITION 1 65 

bed early and encouraged to sleep late. A midday rest for one who 
shows marked emaciation and diminished resistance is advised. 

Illustrative Case. — The following is quite a normal history of an 
advanced case of malnutrition in a girl seven years of age, and the 
treatment is that which we usually employ. The mother brought the 
girl to the out-patient service at the Xew York Polyclinic because the 
child was pale, did not grow, and was always tired — too tired to go to 
school, of which she was very fond, too tired to pla}^ with other chil- 
dren, as had previously been her custom. There was loss of appetite, 
no food being taken except on compulsion. Her weight was forty-one 
pounds, her appearance as above described. There was no evidence 
of congenital syphilis or tuberculosis. There was a secondary ane- 
mia. The child slept in a badly ventilated room, she drank tea and 
coffee. Cake, pastry, and sweets were her regular diet, and because 
she did not eat at meal-times she was allowed to eat between meals 
whenever and whatever she pleased. The following mode of life and 
diet was prescribed. She was to sleep in the front room, known as a 
sitting-room or parlor, with a window open at least six inches. She 
was given three meals a day with nothing whatever between meals. 
The diet consisted of red meat once a day, two or three soft-boiled 
eggs daily, one quart of good milk daily if it agreed, and it did agree. 
She was to have only natural cereals, such as oatmeal, cracked 
wheat, and commeal — each of which was to be cooked three hours 
the day before it was to be given. Baked or boiled potatoes and 
one green vegetable were to form a part of the dinner at midday. 
Stewed and raw fruits and plain puddings with home-made bread 
and plenty of butter completed the dietary. She was put to bed at 
7 o'clock and arose at 7 the following morning. An after-dinner rest 
in a darkened room for an hour was insisted upon. Before retiring 
she w^as given a brine bath (page 31), followed by a brisk drsdngwith 
a rough towel, after which her entire body was rubbed for ten min- 
utes with olive oil. In one month a radical change had taken place. 
She had gained four pounds in weight. Her color was good. She 
complained no more of languor or fatigue. She was eager for school. 
The improvement continued, and in ten weeks she made a perfect 
recoverv\ In not ever}^ case will results be so prompt and satisfac- 
tory, in some, a longer time will be required before pronounced 
results are to be seen. Everv^ child suffering from malnutrition of 
this type cannot help being benefited more or less by such a regime. 

Tonics.— Th^ tincture of nux vomica, four drops in water before 
meals, is sometimes given to these children in whom the appetite is de- 
fective ; or one grain of the citrate of iron and quinin may be given 
in one dram of equal parts of sherry wine and water. 

Constipation.— 'li constipation is present, the oil injection treat- 
ment (page 185) should be instituted, or olive oil may be given inter- 
nally, two to three drams after meals. If the oil is not well taken or 
if it disagrees in any way, of course its use should be discontinued. 



ESSENTIALS IN THE CARE OF ACUTE ILLNESS 

Our first consideration in our relation with a sick child, regard- 
less of the nature of the illness, is to appreciate the changed conditions 
which exist. A well child, regardless of the position he may occupy 
in the social scale, prescribes to a certain living regime, which is sup- 
posed to be so fashioned as to supply the requirements of nutrition 
and healthy growth, which means normal development. Thus, he 
is fed, clothed, he has the benefit of fresh air, exercise, and bathing. 
When the child becomes ill his position temporarily is changed, and 
in order for us to act to his best interest, his daily regime of living 
demands that radical changes be instituted in order to meet this 
changed condition as regards appetite, sleep, the digestive capacity, 
and quiet. The great majority of the serious illnesses in children 
are acute in character. Vitality and resistance determine in no 
small degree the issue of the disease. We must so act as to conserve 
every strength unit. Every child begins the illness with a definite 
number of strength units. 

Our first duty, then, toward the sick child is to place him in 
the most favorable position, in order that he may be able to with- 
stand the ordeal through which he must pass. Regardless of the 
nature of the disease in a child, there are certain requirements that 
must be carried out that apply to all severe illnesses, the general 
management of which in children is very similar. 

Patient to Be Kept in Bed.^ — The patient is to be kept in bed, 
not held on the lap. The handling of the patient, the passing from 
one person to another, the attempt at entertaining, cause active ex- 
citement when quiet is necessary, and waste energy. 

Quiet Attendants. — Attendants who are quiet and agreeable to 
the child should care for him. In my seriously sick cases — pneu- 
monia, endocarditis, and the like — I allow but one person, and that 
the attendant, in the room at one time. 

Clothing.— The clothing of the patient should be the usual night- 
clothing, that to which the child was accustomed in health. There 
is no illness that requires extra clothing for the body when the cus- 
tomary room temperature (66° to 68 ° F.) is allowed. Heavy shirts 
and oiled silk or cotton wool jackets are never employed, regardless 
of the nature of the illness. 

In summer the lightest clothing should be used ; in younger chil- 
dren a thin linen sUp with the addition of a napkin is all that is 

required. 

i66 



SPONGING — DIET 167 

Sponging. — The patient is sponged over once or twice a day for 
cleansing purposes, regardless of the nature of the illness. During 
the hot days of summer the sponging may be repeated several times 
with advantage. There is no disease of childhood in which the appli- 
cation of water to the skin is a dangerous proceedure. On the con- 
trary, it is quite necessary that the skin be so treated that it func- 
tionate actively. 

The Sick Room. — -In summer, a cool, quiet room, large if possi- 
ble, with wide open windows or its equivalent out of doors, should be 
selected for the patient. During the colder months a generous air 
space is most desirable. 

Room Temperature. — In winter the thermometer should never 
go above 70° F. Hot, ill-ventilated roorns depress the vital powers. 
The child is poisoned by carbonic dioxid; he is made restless and 
irritable. He uses up nerve force and energy is wasted. A room 
temperature of 66° to 68° F. is best under most conditions. There 
are few households which cannot have a thermometer. 

Ventilation. — There must always be a communication between 
the sick room and out of doors. A convenient means of ventilation 
is in the use of the window board. A board from four to six inches 
wide is sawed so as to fit under the lower sash. This brings the two 
sashes apart at the top and allows a current of air to be directed 
upward. 

Cold Air. — I am not inclined to advocate cold air to the extreme 
degree that is advised by some. A wide-open window during illness, 
such as convalescence from acute pulmonary disease, I consider an 
excellent measure if the child is suitably protected by a hood and 
ah extra outer garment ; when possible I give the patient the advan- 
tage of two rooms, one for use during the day and one for the night. 
This is of particular advantage in grippe and in the respiratory dis- 
eases in which there is a possibility of reinfection. The room which 
is not occupied should be aired continually. 

Drinking of Water. — ^There is no illness of childhood in which 
water to drink should not be given freely. If there is any question 
as to its purity it should be boiled. 

Diet. — The digestive capacity of every sick child is lessened. This 
we all appreciate ; the degree of incapacity depending largely upon the 
severity and nature of the illness. In every illness the food strength 
should be lessened. This we do not all appreciate. In breast-fed 
babies this is done by giving the child water, sugar-water, or some 
cereal decoction, as barley-water, before each nursing, usually from two 
to three ounces. This dilutes the mother's milk. The nursing baby 
is satisfied when his stomach is full. He needs as much fluid as usual, 
but is unable to digest the usual amount of breast milk. In the 
bottle fed, the food strength is reduced by substituting water for a 
given quantity of the milk mixture. A safe rule to follow is to reduce 



l68 ESSENTIALS IN THE CARE OF ACUTE ILLNESS 

the food strength one-half by the addition of water. If the illness 
is very severe, one of intestinal disorder, whether typhoid fever or 
summer diarrhea, milk is discontinued absolutely and, usually, cereal 
decoctions substituted. During a very severe attack of pneumonia 
of scarlet fever, milk is also discontinued and cereal gruels given. If 
the absence of milk has to be continued for several days, milk-sugar 
is added to the cereal-water substitute so that it shall contain 5 per- 
cent of milk-sugar. This is obviously to supply fuel for the organism 
and spare the proteid tissue. When the usual feeding is continued 
gastro-intestinal infection and intestinal disease is sure to add to the 
burden of the patient through toxins absorbed from the putrefac- 
tion of undigested milk in the gut and through the resulting tympan- 
ites, which is a very serious feature in the respiratory and cardiac 
diseases. Tympanites embarrasses the action of the overworked 
or diseased heart and interferes with respiration already sufhciently 
obstructed by the processes in the lungs or in the pleural cavity. The 
carbohydrates leave no by-products to be eliminated by the kidneys, 
thus lessening the work of these diseased organs and perhaps pre- 
venting their involvement, in such diseases as scarlet fever and 
diphtheria, by diminishing the amount of irritation to which they 
may be subjected. In short, we must allow just as much food as the 
patient can care for. When we give more, we diminish the chances 
of recovery through added toxemias or by interfering with the vital 
processes. 

Needless Interference. — Regardless of the nature of the severe 
illness, we must conserve vitality by disturbing the patient as little 
as possible. The various offices for the child should be done at dis- 
tinct intervals, but make the intervals reasonably long. It is rare 
that a child will need food or medication oftener than once in two 
hours during the night, usually three hours answer in most cases. 
Food and medicine may be given at the same time. Not infrequently 
I see cases in consultation where something is being done to the 
child every hour in the twenty-four. This would exhaust any well 
child. What can the effect be upon the very ill but to diminish his 
chances of recovery? 

Urine Examination.^ — Nephritis. is a complication and a serious 
one, that may be looked for in all acute diseases of children. An early 
recognition of this compHcation is most important. Albumin in the 
urine is one of the earliest signs of nephritis, and involvement of the 
kidneys may be discovered by urine examinations before any of the 
other signs of nephritis appear. It is my custom in scarlet fever 
and diphtheria, diseases peculiarly liable to nephritic involvement, to 
examine the urine daily. In other acute diseases with fever, at two- 
or three-day intervals. This examination is simplified by writing a 
prescription for an ounce of c. p. nitric acid and a few test-tubes, 
which are kept in the sick room. The cold test is sufficient to detect 



BOWEL FUNCTION — DRUGS 1 69 

the smallest trace of albumin. When the physician must carry the 
urine with him or have it sent to his home, the examination is some- 
times postponed or otherwise neglected. 

Bowel Function. — Every nurse or mother is given a standing 
order that there is to be one evacuation of the bowels daily, and if 
this does not occur naturally, an enema is given. 

Bowel Feeding. — In conditions of collapse in any illness, in coma 
and certain gastric disorders particularly, sufficient nutrition cannot 
be given by the stomach. When such a condition obtains, regardless 
of the illness we have to resort to colonic feeding (page 145). 

Suppression of the Urine. ^ — Suppression of the urine is not an 
unusual occurrence in pediatric practice and may occur in a wide 
range of diseases. One of our most successful means of combating 
this condition is in the use of colonic flushings (page 351). 

Pyrexia. — High temperature in children, regardless of the nature 
of the illness, is to be managed by the same methods. The most 
satisfactory in my hands has been the abstraction of heat through 
the means of hydrotherapy, in the use of sponging and packs. It is a 
popular belief among laymen that cold should not be used in scarlet 
fever or measles because of some unfavorable influences excited 
on the rash. There is no disease of childhood with temperature in 
which the application of water to the skin does harm. I use spong- 
ings and packs in scarlet fever exactly the same as in pneumonia or 
typhoid fever. 

When is elevation of the temperature to be interfered with? 
What are the indications that necessitate interference? When we 
have a degree of temperature that causes restlessness, loss of sleep, 
rapid heart w4th resulting loss of vitality — i. e., wasted energy^ — then 
I believe that means for reduction should be instituted. This will 
be necessary in some patients at 103° F. In others at 105° F. In 
other words, we should be governed largely by the effects of the tem- 
perature upon the individual and not by the reading of the ther- 
mometer. If sponging is employed, I use one part alcohol with three 
parts of water at about 80° F. The skin is repeatedly moistened 
with the solution, which is allowed to evaporate. In some patients 
such a procedure is soothing. In others it occasions no little annoy- 
ance, in which event it must not be used. By far the most satisfactory 
hydrotherapeutic means is in the use of the pack (page 503). 

Drugs. — -Regardless of the nature of the disease, a full dose of 
castor oil cannot help but be of benefit at the beginning of the illness. 
Every child admitted into the Babies' Hospital of New York City 
gets two teaspoonfuls of castor oil and a bath. 

In the use of drugs in children it is quite necessary to use them 
so that harm may not follow. 

In any illness in a child one feature to bear in mind is to keep 
on good terms with the child's digestive tract. In our medication 



lyo BSSEJNTIALS IN TH^ CARE OF ACUTE ILLNESS 

we must seek to protect the stomach. This may be done by giving 
much of the medication after meals, using it in capsules, powder, 
or tablet by preference; it is to be given well diluted with water 
when administered between meals. When liquid medication is neces- 
sary, elixir simplex in small amount is employed as a flavoring 
medium. Avoid the useless syrups. The worst possible medication, 
to my mind, is the custom of using heavy syrups for flavoring meas- 
ures. The practice of giving the ammonia salts and ipecac, usually 
with syrup of Tolu, to a child with severe bronchitis or broncho- 
pneumonia is wretched practice, and this is putting it mildly. 

Stimulation. — I have two criticisms of general application as 
relates to the management of sick children. The first is that heart 
stimulants are used too early and in too large dosage, and that anti- 
pyretic measures are resorted to when such management is not called 
for. I have already referred to the latter in stating that a child 
should not necessarily have antipyretic measures used because he has 
fever with his pneumonia or typhoid or scarlet fever. Neither does 
he require stimulation because he has typhoid or scarlet fever or 
pneumonia. Regardless of the nature of the illness, our choice of 
stimulants is very much the same and our reason for using them is 
exactly the same, in that we have a heart that needs help. Details 
as to the employment of heart stimulants and the drug used will be 
found under proper headings in the different chapters. 

It will thus be seen from the foregoing that the treatment of differ- 
ent diseases of children has many features in common, and these 
essentials must be appreciated by every man in order that he do the 
best work in treating diseases of children. 

If there is one thing that has been impressed upon me in an active 
life of twenty years in childrens' work, it is the necessity of the com- 
pleteness of detail in our management of children. We little realize 
how sensitive the sick child is, how all nervous effort, all untoward 
influences cost something. They cost energy and output of vitaHty 
which may be sufficient to determine the issue for recovery or against 
it. Family co-operation is necessary for success, and will be best 
obtained through the confidence and affection engendered by thor- 
ough, painstaking work on the part of the physician. 



GASTRO-ENTERIC DISEASES 

ACUTE INTESTINAL INDIGESTION 

This disorder is first referred to because, according to my obser- 
vation, it is the most frequently seen of the intestinal disorders. 
Its importance not being recognized, it receives but little considera- 
tion in its bearing upon prophylaxis and treatment. The proper 
appreciation and management of a disordered intestinal function 
are essential to the solution of that most important problem — summer 
diarrhea. As pointed out elsewhere, the intestine which furnishes 
the most fertile field for bacterial growth is the intestine which is 
persistently deranged. 

The mortality of summer diarrhea in June in Greater New York 
in children under two years of age is usually but from three hundred 
to five hundred less than in August. The high June mortality has 
been explained by the fact that it includes many cases of malnutri- 
tion and marasmus ; but it must be remembered that it includes also 
cases of a diminished intestinal resistance, which are ready subjects 
for the almost invariable exposure to which every bottle-fed infant 
is subjected at some time during the summer, w^hen heat and humid- 
ity aid in lowering the general vitality — exposure through infected 
food. A close investigation of hundreds of cases of severe acute 
disorders of infants has shown that a great majority of them are not 
as acute as a superficial history would indicate. A complete history 
in a case of acute gastro- enteric infection (cholera infantum) or 
in an apparently severe intestinal infection with resulting colitis, 
or in an acute colitis (dysentery), will show that the child had 
defective intestinal digestion during the previous cold months, 
and that the grave condition which he presented when brought for 
treatment had been preceded for two or more days by simple diar- 
rhea, probably without vomiting and with little fever, but he did 
have green passages and he did have diarrhea. He therefore had 
intestinal indigestion before the urgent symptoms of fever and pros- 
tration developed. In about i percent of the cases of severe gastro- 
enteric diseases of children in summer the onset is sudden, without 
warning and with urgent symptoms. 

Treatment. — The time to treat these cases of intestinal indiges- 
tion, in order to be most effective in the prevention of severe toxemia 
and grave lesions, is before the physician sees the patient. The reduc- 
tion in the mortality rests in the education of the mother to the point 
of realizing that a loose green stool is a danger-signal. When it 

171 



172 GASTRO-ENTERIC DISEASES 

occurs, she is to give a dose of castor oil, two teaspoonfuls, stop the 
bottle or stop the breast, and give the baby boiled water or barley- 
water until the physician can see the patient. Any physician who 
has children under his care, whether in hospital, institution, out- 
patient, or private practice, and who does not so instruct the nurse 
or mother, fails in his obligation as a practitioner of medicine. 

. In the Breast-fed. — Intestinal disease of severity in infants fed en- 
tirely on the breast is exceedingly rare. In a breast-fed baby it may 
be necessary to discontinue nursing for from twelve to thirty-six hours. 
The child is given one or two drams of castor oil and barley-water or 
rice-water No. i (seepage 129), to which one-half or one-fourth 
ounce of cane-sugar is added to the pint. While nursing is discon- 
tinued the breasts should be pumped at the regular nursing hour so 
as to keep up the flow of milk and relieve the pressure. Rarely will 
other treatment be required. 

In the Bottle-fed. — In the bottle-fed, greater caution will be neces- 
sary. The management consists in continuing the carbohydrate diet, 
which the well-tramea mother has begun, until the stools approximate 
the normal, which may necessitate an abstinence from milk for three 
or four days, by which time it may usually be resumed. In resuming 
the milk it should always be given in reduced quantities for the first day. 
One-half ounce of skimmed milk may be added to every second feed- 
ing or to every feeding of the gruel. If it is well digested and causes no 
return of the diarrhea, the amount of milk may be increased tenta- 
tively every day or two by the addition of one-half ounce to each 
feeding. 

PERSISTENT INTESTINAL INDIGESTION 
A greater part of this subject has been covered in the consideration 
of the management of malnutrition and marasmus. It is again 
referred to here in order to call attention to those cases which, 
though mild in character, are so important an etiologic factor in the 
acute intestinal diseases of summer. There is perhaps not enough 
bowel disturbance to interfere with the nutrition, but we have 
learned that a considerable part of the summer mortality of acute 
intestinal diseases occurs in children who have a reduced intestinal 
resistance as a result of persistent intestinal, indigestion. 

A considerable number of infants do not have normal bowel 
evacuations even for two days out of ten. There is constipation 
which is neglected, or there is a passage of undigested or loose 
stools. In some cases constipation alternates with diarrhea. 
Occasionally there is a sharp attack of diarrhea with fever. In 
getting the history of our cases regardless of the nature of the illness, 
we often learn that, as a rule, the infants have undigested stools. 
There is always an unstable intestinal equilibrium. This condition 
of intestinal indigestion is almost without exception due to errors 



PERSISTENT INTESTINAL INDIGESTION IN OLDER CHILDREN 1 73 

in diet — either unsuitable articles of food being given habitually, or 
the food is too strong or the feeding intervals too short. 

Treatment. — ^The management of each case is determined by the 
age of the patient and the conditions of the family, and will be dis- 
cussed in the sections relating to Nutrition, Substitute Feeding, and 
Modification and Adaptation of Foods. 

PERSISTENT INTESTINAL INDIGESTION IN OLDER CHILDREN 

In such cases there may be a sufficient absorption of toxins of 
an unknown nature from the intestinal canal to produce a wide range 
of symptoms. Whether this causes pathologic conditions in other 
organs it is not possible to state. It is assumed, however, that it 
does. Comparatively little attention appears to have been given the 
subject. There is no doubt whatever that it is a factor of great 
importance in the nutritional and the so-called functional nervous 
disorders of childhood. One reason why little attention has been 
called to the intestinal tract as an etiologic factor is perhaps because 
the child is not necessarily constipated. Intestinal toxemia may exist 
with one or two apparently normal passages daily and even without 
the presence of indican in the urine. 

In my cases the conditions in which it has seemed to play a 
part sufficient to form a symptom-complex have been habitual 
headache, disorders of speech, choreic in character, secondary 
anemia, habitual sleep-talking, sleep-walking, and general irri- 
tability without apparent cause. Well children are natur- 
ally bright and happy. When a child is persistently cross and 
irritable, he is not a well child. Chronic papular eczema has 
proved to be of intestinal origin in a considerable number of my 
cases, particularly among the out-patient class. The condition 
often regarded and treated as malaria is not infrequently due to 
intestinal toxemia. Fever of a degree or two may be present for 
protracted periods. Nearly every case w^hich has come under my 
care had been given at some time or other a course of quinin. 
Such a patient is very apt to be habitually tired and languid. He 
may be fairly bright early in the day, but in the afternoon he yawns 
and complains of being tired and sleepy. The blood examination 
fails to reveal signs of malarial infection, and quinin in full doses 
furnishes no relief. The appetite may be satisfactory, the tongue 
may show no signs of digestive disorder. The symptom-complex 
which suggests to the mother the thought of worms is usually the 
manifestation of intestinal toxemia. 

Illustrative Cases. — An interesting case of this nature came under 
my care a few years ago. The boy, aged three years, highly ner- 
vous and irritable, was afflicted with day terrors^/?a7;or diurnum. 
The attention of the nurse was attracted to the condition by the 
boy, who asked that the "bugs" be removed from his lap-robe 



174 GASTRO-ENTERIC DISEASES 

when he was in his go-cart. It was in the middle of winter and 
there were no bugs present. I fortunately saw the boy on one of 
these occasions and asked him to pick up a bug, which he tried to 
do with his fingers. He could not understand why he could not 
catch them. In this child the tongue was heavily coated and there 
was moderate constipation, a laxative being required every third 
day. There was an excess of indican in the urine. The boy was 
taking a large amount of rich cow's milk daily. After stopping 
this, a full dose of rhubarb and soda was given daily and the boy 
was well in a week. 

A boy five years old was brought to me because of disturbance 
of speech. He was normal until three and one-half years of age, when 
he had difficulty in the formation of entire words. This had increased 
with the development of other nervous phenomena. There was 
marked incoordination in speech — dysarthria — ^due to choreic move- 
ments evidently of the tongue and laryngeal muscles. The boy was 
exceptionally well nourished and there was an absence of choreic 
movements in other parts of the body. The knee reflexes were con- 
siderably increased. He was easily excited. Hard play was followed 
by restless nights, and he talked in his sleep every night, regardless 
of the habits of the day. Inquiry into the diet failed to elicit any 
grave errors. He drank one quart of milk daily, but milk had never 
agreed with him as an infant. The bowels moved once daily. The 
movements were often of foul odor and the mother stated that she 
was satisfied they were too small. The case after three weeks showed 
striking improvement on a non-milk diet with a daily laxative, and 
made a complete recovery in three months. 

A third case seen was a girl six years of age who lived in the best 
surroundings in a country district. She was pale, rather thin, and 
below weight for her age. She was chronically tired and irritable 
and had been so for two years. Examination of the blood showed 
a secondary anemia, and of the urine a marked excess of indican. 
She had been taking quantities of quinin. There was no constipation, 
the child had an indifferent appetite. She favored milk and was 
paid for drinking extra quantities of it — about two quarts daily being 
taken. Marked improvement followed the treatment by an ab- 
sence of milk from the diet and laxatives, after which she passed 
from my observation. 

The condition of intestinal toxemia is probably due to changes 
taking place in the proteid content of the intestine. In the three 
cases mentioned, milk was a considerable part of the diet; in fact, 
in the majority of my cases, milk had been taken in considerable 
quantities. 

Treatment. — In my experience the management of these cases, 
which has been most successful, has been the discontinuance of 
cow's milk, with the further dietetic suggestions of but one egg 



COLIC 175 

every second day, and meat but once daily. Cereals, fruit, and 
vegetables are taken as suggested in the Dietary (page 134). The 
use of green vegetables is particularly encouraged. In place of cow's 
milk, malted milk is given, and to facilitate the bowel action, a raw 
apple is given in the middle of the afternoon. The patient takes 
an after-dinner rest for an hour or two. If constipation is obstinate, 
rhubarb and soda of the following strength are used : 

I^. Pulveris rhei S^- ^X. . 

Sodii bicarbonatis gr. viij 

Syrupi rhei aromatici 5ss 

Aquse q. s. ad 3 j 

M. ft. 

Sig. — ^One teaspoonful once or twice daily 

Or, what I prefer, if the child can take a capsule, is the following 
for a child from five to eight years of age: 

I^. Tincturae belladonnae gtt. ij 

Tincturae nucis vomicae gtt. iv 

Extracti cascarae sagradae gr. j-iij 

Sodii bicarbonatis gr. iij 

M. ft. capsula No. i. 

Sig. — To be taken at bedtime. 

The medication ma}^ be continued for three or four weeks, after 
which time one dram of the syrup of the hypophosphites (Gardner's) 
may be given three times a day. This may be alternated with : 

I^. Ferri et ammonii citratis gr. xxiv 

Elixiris simplicis ,^j 

Aquae q. s. ad iv 

Sig. — One teaspoonful three times daily after meals. 

In the event of constipation following the use of the laxative, 
the oil treatment (page 185) may be brought into use and continued 
until the condition is relieved. 

COLIC 

But few children complete their first year without having severe 
attacks of colic. In some cases the child thrives in spite of the 
attacks, in others such a grave degree of indigestion exists that the 
condition may prove most serious. The character of both human 
and cow's milk, its ready decomposition in the intestine, w^ith the 
formation of gas, together with the lack of development of the 
infant's digestive apparatus, explain in no small degree the frequency 
of colic in the voung. When cow's milk is used as in the bottle-fed, 
we are aealing with a substance foreign to the infant's digestive 
apparatus, and often colic is the outcome. Any condition that 
will give rise to indigestion may, of course, be a cause of colic. 
Those children that take too much milk, too strong milk, or who 



176 GASTRO-ENTERIC DISEASES 

take milk too frequently are the usual subjects of colic. Proba- 
bly the most frequent cause of colic is an indigestion of the proteid 
of the milk. Either the proteid is in excess or the child has a poor 
proteid capacity. Not a few cases of colic are due secondarily to 
defective bowel action. A passage occurs each day, but in too 
small amount. There is a continual fecal residue in the intestine 
which undergoes decomposition with gas-formation. Cold feet are 
often associated with colic. Fright, anger, fatigue, excitement — 
any condition, in short, which may make a sufhciently unfavorable 
impression upon the child's nervous organism, may produce indi- 
gestion and colic. 

Likewise any adverse nervous mental state in the mother may 
produce colic in the breast baby. Constipation in the mother is 
not an infrequent cause. 

Treatment. — Repeatedly I have had under my care nursing 
babies who suffered from habitual colic and who recovered after 
the regulation of the mother's bowels by exercise, diet, and medica- 
tion. In other breast cases in which the mother's milk upon re- 
peated examination proves too strong and the child suffers daily 
from colic, a dilution of the milk may be made by the use of plain 
water or barley-water, from one-half ounce to one and one-half 
ounces of the diluent being given before each nursing. In addition 
to the above, the bowels of the colicky infant should move at 
least twice daily, morning and evening. When this does not take 
place readily a simple laxative, such as milk of magnesia, one- 
half to one teaspoonful, or ten to thirty drops of aromatic cascara 
sagrada, may be given daily. Under no condition should a child 
subject to colic, be allowed to go without a bowel evacuation for 
more than twenty-four hours. 

Diet. — The dietetic management of colic in the bottle-fed consists 
in adapting the food to the child's digestive capacity. The bottle 
baby may have habitual colic moderately and thrive, but he does 
it on an imperfectly adapted food. Here, as in the breast-fed, the 
condition is usually dependent upon an excessive casein supply or 
a diminished casein capacity. The matter of the adjustment of cow's- 
milk proteid in indigestion is discussed in detail under Milk Adap- 
tation (page 106). It is sufficient to say that the colicky bottle 
baby should have long intervals between feedings — usually one-half 
hour longer than otherwise allowed. Digestion is slower in many 
of these cases, although in other respects they may be healthy 
children. In some the indigestion and pain are so severe that a 
perfect adaptation of cow's milk is impossible, and some other food 
than cow's milk will be required. 

Enemas. — The prevention of colic, then, it will be seen, rests 
upon a proper adjustment of the food. The immediate attack is 
usually best relieved by the use of an enema at 110° F. of a normal 



BOWEL FUNCTION 1 77 

salt solution or of soapsuds, which, by inducing a movement of the 
bowels, allows the gas to escape. 

Medication. — A soda mint tablet dissolved in one ounce of hot 
water, given in one-teaspoonful doses repeated at five-minute in- 
tervals, is sometimes successful. For a child under one year of age 
three drops of spts. aetheris comp. (Hoffman's anodyne) may be given 
in two teaspoonfuls of hot water and repeated at ten-minute inter- 
vals. From five to ten drops of gin, when given in three teaspoonfuls 
of hot water, may be used, and repeated in from ten to fifteen minutes 
if the attack continues. 

Hot Applications.- — ^Hot applications to the abdomen are often 
grateful to the patient. For this purpose ten drops of turpentine 
in one quart of water at 120° F. may be used with benefi.t. A 
flannel is wrung out of the water or the solution and applied over 
the abdomen and covered with a dry piece of flannel. The dressing 
may be changed every ten or fifteen minutes. 

Opium and its derivatives should not be used in the treatment 
of colic. It may relieve the pain temporarily, but it aggravates 
the condition to which the colic is due. 

BOWEL FUNCTION 
In order to keep the infant or young child in good physical con- 
dition, one free evacuation of the bowels is required once in twenty- 
four hours. While two or three evacuations daily in a nursing or 
bottle baby may be desirable, this number is not absolutely necessary. 
When there are more than four passages in twenty-four hours, it 
means that something is wrong with the intestinal tract. This, 
however, may not be of such a nature as to require radical means for 
its correction. Thus, in many nursing babies who are supplied with 
a high-fat breast-milk there may be several thin greenish stools in 
twenty-four hours, in spite of which condition the child thrives 
satisfactorily. It is well in these cases to attempt to reduce the 
fat in the breast-milk by measures suggested elsewhere, but by no 
means should the nursing be interdicted if the baby is making a 
reasonable gain in weight. The proof of successful nursing is a 
thriving child, not the character of the stool. The habit of an 
evacuation at a certain time each day is one of the most important 
preventives of constipation in an infant. There is a standing order 
in every household where I have such a patient, to the effect that 
the child is never to be put to bed for the night unless the bowels 
have moved during the preceding twenty-four hours. Either a 
simple soap-and-water enema or a small glycerin suppository is 
employed. The enema is preferred, from four to eight ounces of 
the soap-water being used. The suppository is used only when, for 
any good reason, the enema is not available. Placing the child 
at stool immediately after the morning bottle is one of the means 



1 78 GASTRO-KNTKRIC DISHASE:S 

of establishing the habit of an evacuation at a definite time each 
day. The child soon appreciates the reason for this position and 
acts accordingly. This practice may be begun when the child is 
five or six months of age. 

Defective Bowel Evacuation. — Defective bowel evacuation in 
infants and young children is a form of constipation very apt to be 
overlooked, and for this reason it is put under an independent head- 
ing. As long as an evacuation takes place daily it is supposed to be 
sufficient. Even though a passage takes place daily and voluntarily, 
if it is dry and comes away in pieces or in hard balls, or is firmly 
formed without the moist surfaces caused by the presence of mucus 
and water, it is practically certain that the evacuation is not com- 
plete and that fecal matter is retained in the intestine. This may 
occur at any age, and when the condition persists, there results, 
oftentimes, an intestinal toxemia, with the manifestations referred 
to under that caption (page 202). The same methods of treatment 
are to be followed as suggested in the preceding chapters on consti- 
pation for the various ages of infancy and childhood. Usually, 
however, in this type of constipation, dietetic measures are sufficient. 

Constipation in Nurslings. — There are many nursing infants, 
who are thriving and well in every respect, except that they are con- 
stipated. There is greatly delayed or no bowel evacuation without 
aid. Our first step in the management of these cases is to examine 
into the daily life and habits of the mother. A factor in the etiology 
of constipation in the infant is constipation in the mother, which, 
if relieved by diet or medication, will often relieve the child; or if 
not relieved, the subsequent treatment directed toward the child 
will be much less effective. Nursing women who drink a great 
deal of tea are apt to be constipated, and their infants likewise. 
The nurslings of mothers who lead indolent lives, taking but little 
exercise, are likewise sufferers from constipation. 

Treatment of the Mother. — Errors in the mother's diet and habits 
of life must be corrected and the scheme carried out which is re- 
commended on page 69. 

Having established a proper regime for the mother, the breast- 
milk should be examined (page 64) . While high proteid may mean 
constipation, it is rare, in my observation, to find this a cause. Low 
fat, from 1.5 to 2.5 percent, with normal proteid is much oftener 
found to be present in these cases. 

Often in such cases the fat in the mother's milk may be increased 
by the use of some form of alcohol, given with the meals. Wine, 
beer, ale, porter, or the liquid malt preparations may be given, the 
mother being allowed to make her own selection according to her 
taste. The free eating of red meats also increases the fat in the milk. 

Several years ago a series of observations were made in the New 
York Infant Asylum relating to the effects of diet on breast-milk. 



BOWEL FUNCTION 1 79 

It was found that in some cases the fat could be increased from i to 
2 percent by the addition of alcohol to the mother's diet. The 
value of the various galactagogs on the market depends, in all 
probability, upon the alcohol which they contain. 

Treatment of the Child. — From the standpoint of nutrition and 
as a laxative, a valuable addition to the diet of the constipated 
breast-fed infant, when the mother's milk is found weak in fat, is 
cow's-milk cream, one-half to one teaspoonful being given before 
every second nursing or before every nursing, according to the 
age of the child and his capacity for fat digestion. Children during 
the early months of life take pure cod-liver oil readily, which, like 
cream, may serve the double function of a food and a laxative. 
Establishing by careful instruction the habit of an evacuation of the 
bowels at a certain time every day, is a valuable measure in all 
children. 

Drugs. — Drug-giving is rarely necessary in young children and 
should be resorted to only when other measures fail. In case drugs 
are necessary, those most useful ordinarily are the preparations of 
cascara sagrada. The aromatic fluid extract (Parke, Davis & Co.) 
is palatable and may be given in sufficient doses to be effective once 
or twice daily. The milk of magnesia with equal parts of the 
aromatic syrup of rhubarb, given in doses of from one to three tea- 
spoonfuls daily, is an agreeable and usually an effective combina- 
tion. 

Enemata and Suppositories. — The use of water enemata and sup- 
positories is not to be advised as a routine measure. The habit of 
depending upon them is readily established, the parts by their fre- 
quent use become insensitive to stimulation, and in a few weeks 
they fail to act. I have had many mothers come to me for the first 
time in great distress when this stage was reached. When the 
stool is dry and hard and is passed with difficulty, the injection of 
two ounces of warm sweet oil at bedtime is of advantage. This is 
not with the idea of producing an immediate evacuation, but rather 
to act as a lubricant for the evacuation expected the following 
morning. 

Malted Foods. — It is elsewhere advised that the nursing baby be 
given one bottle-feeding daily. The malted proprietary foods are 
distinctly laxative to many children. It has long been my custom, 
when in a nursing infant a condition of constipation exists which 
is not relieved by careful regulation of the mother's diet, to pre- 
scribe one feeding of malted milk daily, the food being given usually 
in the strength of one teaspoonful to an ounce of water. Some 
children will not take it in this strength, as the sweet taste is objec- 
tionable. In such cases it may be given weaker at the beginning, 
or it may be given in a milk mixture suitable to the age of the 
child; but when used in this way, there should be no addition of 



l8o GASTRO-KNTERIC DISEASES 

sugar. Malted milk or Mellin's food may be used in a quantity 
equal to that of the sugar. 

Massage is a most valuable means of treatment in the constipation 
of older children, but in nurslings and in the bottle-fed of tender age, 
on account of the restlessness and crying, it is not generally practi- 
cable, and to be effective it requires that it should be given only by 
those skilled in its use; therefore, unless the case is an extreme one, 
and all other measures have failed, massage is not to be employed 
in the very young. I have never seen any benefit from the abdominal 
manipulations attempted by the mother or nurse. 

Treatment of Constipation in the Bottle-fed. — In the bottle-fed, 
inactivity of the bowel is more easily managed than in the nurs- 
ling, because in the former we are in a better position to adapt 
the food to the child's digestive peculiarities. As a rule, consti- 
pated bottle babies should have a reasonably high fat — 3.5 to 4 
percent — and sugar up to at least 7 percent, but, as with all rules, 
this one is open to exceptions, a few of the most obstinate cases 
of constipation that have come under my care being those fed on 
a very high fat, the constipation being due to fat indigestion. It 
is extremely rare to find a child who can digest, day after day, a 
milk mixture containing more than 4 percent of cow's-milk fat. 

The Proteid. — Cow's-milk casein is probably the most fruitful 
factor in causing constipation in bottle-fed babies, nevertheless 
it is necessary for the child's nutrition. A considerable reduction, 
such as may be obtained by giving a mixture of cream, sugar, and 
water, may relieve the constipation, but the child suffers from a nu- 
tritional standpoint, and instead of having a constipated baby to 
deal with we have a rachitic one, which is much worse. In not 
a few instances I have seen malnutrition result from cutting down 
the proteid, in the effort to relieve constipation. 

The child's growth and development should most concern us in 
our relations with him, and this should never be subservient to any- 
thing else. A child under six months of age will not thrive satis- 
factorily on less than i percent of proteid as found in cow's milk. 
He is entitled to at least 1.5 percent, and thrives best when this 
amount is given. The relief of the constipation can in almost 
every instance be accomplished by other means than a too great 
reduction in the casein — the most nutritive element in the infant's 
food. 

Milk given constipated infants should always be raw, as cook- 
ing increases its constipating tendency. 

Laxative Agents in the Food. — ^The simplest means of treating 
constipation in the bottle-fed is by the employment of a laxative 
agent in the food, and when such an agent adds to its nutritive 
value, it serves a double purpose. Instead of using water as a 
diluent, oatmeal-water No. i (see Formulary) may be employed. 



BOWEL FUNCTION l8l 

The malted proprietary foods, such as MeUin's food, and malted milk 
are laxative to most children. Mellin's food is composed largely 
of sugar, and therefore it may be used in place of sugar-of-milk or 
cane-sugar in the food mixture, and has thus served me well in re- 
lieving constipation. In some instances I substitute a feeding of 
malted milk once daily for the regular milk food, with from four 
to eight ounces of water, the quantity and strength depending, 
of course, upon the age of the child. 

Drugs and Local Pleasures. — Dietetic measures should always be 
tried before drugs are resorted to, for when drugs are used, we have 
to give them in constantly increasing doses, and they soon become 
ineffective. One or two teaspoonfuls of milk of magnesia in one 
bottle daily may be recommended as a temporary expedient in some 
cases. The magnesia may be of service until the condition is con- 
trolled by the diet. The aromatic fluidextract of cascara sagrada, 
in doses of from fifteen drops to one dram, may be tried if success 
does not follow the use of the magnesia. 

Water enemata and suppositories should be used only as tem- 
porary measures. Orange- juice, two teaspoonfuls, twice daily be- 
fore feedings, is worthy of trial and is of antiscorbutic value in 
children artificially fed. Sweet oil and the pure cod-liver oil may 
also be used in doses from thirty drops to two drams, three times 
daily, after feedings, if the patient shows a tendency to rachitis or to 
general malnutrition. In the use of the oils, we have their beneficial 
effects not only as laxatives but also as aids to nutrition. 

Oil Injections. — In case the stool remains hard and dry, in spite 
of the above suggestions, an injection of two ounces of warm sweet 
oil (page 185) may be given at bedtime every night, not with a 
view of inducing a passage at the time, but as a lubricant to the 
parts and as a solvent of the hard fecal masses. 

Constipation in Older Children. — Etiology. — Probably the most 
potent dietetic factor in causing constipation in children of the 
"runabout" age is the use of full milk. Particularly is this apt to 
be the case if the milk is boiled. Constipation may be occasioned, 
further, by a too great concentration of the food, insufiicient volume 
being furnished to produce copious evacuations. 

Local Causes. — In a great majority of children the freer feed- 
ing following weaning from the breast and bottle relieves the ten- 
dency to constipation from which many children suffer during the 
earlier months of life. In a small percentage of cases, however, 
such relief is not furnished, and the child will require the attention of 
a physician. In making the physical examination of a case of this 
nature, special care should be directed toward the examination of 
the rectum, in order that local causes, such as fissures or hemorrhoids, 
may be eliminated. If fissures are present, the child will use every 
effort to prevent a bowel movement. 



1 82 GASTRO-KNTERIC DISEASES 

Regular Habits. — As a rule, children who are presented for treat- 
ment after the second year have not had the benefit of carefully reg^ 
ulated habits of life, so that our first step is to correct bad habits, 
that may have a bearing on the condition, and to teach good ones. 
The desirability of establishing in the child the habit of a bowel 
evacuation at a certain definite time every day should be impressed 
upon the mother or nurse. In order to bring this about, an attempt 
should be made to induce a movement of the bowels by voluntary 
effort every morning after breakfast. Not a few children are too 
busy, too active in their play, to respond to the call of nature when 
it comes, and if it can be repressed, they say nothing about it. If 
a certain time of the day is selected for the evacuation, and if they 
have to remain at stool until it occurs naturally, or by means of a 
suppository after fifteen minutes have elapsed, much is accom- 
plished by this means alone toward estabhshing the habit. 

Diet. — Ultimately, much may be accomplished in these cases by 
diet. Foods other than milk may now be given, so that a high- 
proteid milk, a milk rich in casein, is not necessary. As it is de- 
sirable to continue the use of milk at this age, the following com- 
bination of top milk and water may be used instead of full milk. A 
quart bottle of cow's milk is allowed to stand at a temperature of be- 
tween 40° and 50° F. for five hours, when the top ten ounces are 
removed. The skimming is best done with a Chapin dipper (see 
Fig. 12, page 94). The ten ounces of top milk are mixed with 
twenty ounces of oatmeal gruel or plain boiled water and given as a 
drink. 

The giving of high-fat mixtures in constipation is sometimes 
overdone even in older children. We seldom find a child five years 
of age who can digest, day after day, a milk or cream mixture con- 
taining over 4 percent of fat. Attacks of acute indigestion and 
faulty nutrition are very apt to result when too high a fat is persist- 
ently given. In not a few instances I have seen grave malnutrition 
result from an attempt to relieve the constipation by high-fat feeding. 
It must also be remembered that high-fat mixtures may produce 
constipation in children of any age, hard, very light colored, usually 
foul-smelling stools resulting. By using the top milk, diluted, we 
give a sufficient amount of fat and relieve the constipation by re- 
moving a considerable percentage of the casein, the usual constipat- 
ing element, the percentage of which in the thirty ounces of food, 
above referred to, is but one-third that in full milk. Of course, the 
nutritive value of the dilution is less than that of full milk, but the 
child is now at an age when proteid can be given in other forms 
than in the milk. 

White wheaten bread, wheaten flour crackers, with full raw milk 
should form no part of the dietary of our patients. It is best to give 
to parents of children we are treating for constipation a list of per- 



BOWEL FUNCTION 1 83 

missible articles of food from which they are instructed to make up 
suitable meals. The following articles of diet may be allowed : 

Animal broths, purees of Hashed chicken. 

peas, beans, and lentils. Lamb chops. 
Rare roast beef. Soft-boiled eggs. 

Rare steak. 

Green vegetables, such as : 

Peas. Asparagus. 

String-beans. Strained stewed tomatoes. 

Spinach. Cauliflower, mashed. 

Cereals, as follows (each cooked for three hours) : 
Cracked wheat. Hominy. 

Oatmeal. Cornmeal. 

The cereals may be served with a small amount of milk and sugar, or 
better with butter and sugar. 

Bran biscuits. Zwieback. 

Oatmeal crackers. Whole wheaten bread. 

Graham wafers. 

Desserts : 

Stewed or baked apple. Cornstarch. 

Stewed prunes. Plain vanilla ice-cream. 

Custard. Junket. 



Malted milk may be given as a drink. Six teaspoonfuls of malted 
milk in eight ounces of hot water may be given once or twice daily. 
An agreeable change in taste of the malted milk may be made by the 
addition of a teaspoonful of cocoa. If milk is given as a drink, the 
top ten ounces from a quart bottle should be used as described 
above, mixed with twenty ounces of boiled water or oat-meal jelly. 
A child in fair health after the second year usually thrives best 
on three meals daily. If he is deHcate or if a fourth meal does not 
interfere with the appetite for the other meals, it may be allowed. 
The extra meal, however, should be light, and is best given at from 
2 to 3 o'clock in the afternoon. For a child suffering from consti- 
pation, it may consist of a cup of broth with a graham or oatmeal 
cracker. Orange-juice or a scraped raw apple may also be given at 
this time. When only three meals are allowed, the orange-juice or 
scraped apple should be given in the afternoon about two hours 
before the evening meal. The giving of the fruit-juice or the apple 
on an empty stomach is a valuable aid in relieving chronic constipa- 
tion. These patients should also be encouraged to eat plenty of 
butter. The use of olive oil internally is of as much service here as 
in bottle or nursing babies ; from two to three teaspoonfuls are given 



184 GASTRO-HNTERIC DISKASKS 

after each meal. It is usually well borne by the stomach ; in fact, 
many children become very fond of it. Inasmuch as it is more of the 
nature of a food than a medicine, its use may be continued for months 
if necessary. 

Treatment after the Fifth Year. — Permissible articles for a child 
of from five to ten years of age include those mentioned above, with 
the addition of dates, figs, raw and cooked fruits, baked and stewed 
potatoes, meats, baked and broiled poultry, and fish. The latter 
should be served plain without sauce. Plain puddings may also be 
allowed. One or two raw apples, an orange or a large peach or 
pear, should be given every afternoon. It is not promised that in 
a case of chronic constipation the above diet will at once produce 
normal bowel movements. The diet must be continued for weeks 
in some cases before marked benefit will be observed; in others 
the results are very prompt and satisfactory. Enemata and sup- 
positories will be necessary at first until the habit of an evacuation 
of the bowels at a certain time every day is established. 

Drugs. — Drugs also may be of temporary service. The cascara 
preparations are the best that we possess for this condition. If the 
child can swallow a pill or a tablet, the drug may be given in this form. 
The one-grain tablets of cascara may be ordered and the nurse in- 
structed to give from one to three or four at bedtime. If the drug 
has been properly prepared from the well-seasoned bark, with a rea- 
sonable dose, there will be no griping, and the amount given on 
succeeding nights may be diminished instead of increased, as is 
often necessary with many other laxatives. Its use should not be 
continued longer than two weeks. If the daily evacuation habit is 
not estabHshed at that time, it will not be formed by further drug- 
ging. If the pill or tablet cannot be swallowed, then the aromatic 
fluidextract of cascara in doses of from one-half dram to one dram 
may be given. Castor oil, calomel, or podophyllin should never be 
given without other indications than simple constipation. In the 
cases in which the stools are soft when passed, but difiicult of pass- 
age because of deficient peristalsis, the tinctures of nux vomica and 
belladonna may be given with benefit, if continued for a considerable 
time. A child three years of age may be given three drops of the 
tincture of nux vomica and two drops of the tincture of belladonna 
three times daily in pill, capsule, or liquid form. The constipation 
which accompanies mucous colitis is referred to under that heading. 

Treatment of Obstinate Constipation. — Despite both diet and 
drugs, we meet at infrequent intervals cases which, without struc- 
tural deformity, resist our every effort. Drugs, attempts at habit- 
forming, and diet have been used and failed until only the most 
radical measures along these lines furnish relief. In such cases of 
obstinate constipation, I use the following means of management. 
Laxative drugs are not given. 

Diet. — Milk and cream are prohibited except in sufficient amount 



BOW^L FUNCTION 1 85 

to make the morning and evening cereal palatable. For this purpose 
not over two ounces of milk are needed. I prefer that cereals be 
taken with butter and sugar. Aside from practically cutting off milk 
from the diet, the dietetic measures are the same as mentioned above. 
Oil Injections. — For this purpose a soft-bulb syringe of four 
ounces capacity is ordered. Over the hard-rubber tip is placed a 
small sized adult rectal tube or a No. 18 American catheter. The 
catheter or tube is cut so that but nine inches remain for use. The 
cut end is forced over the small hard-rubber tip of the syringe 
(Fig. 19). A fountain syringe is impracticable for this purpose, 
as it is soon destroyed by the oil and rendered unfit for use. Be- 
sides, sufficient pressure is not produced to force the oil into the 
gut even with a high elevation of the bag. The child is placed on his 

back or on his left side, preferably in 
the Sims position. The syringe is 
filled with oil, the tube is lubri- 




FiG. 19. — BrLB Syringe and Catheter 
FOR Oil Injection. 

cated, and passed through the rectum on into the descending 
colon. When it has been passed to the full nine inches, as may 
readily be done with a little practice, the syringe is emptied 
and the tube withdrawn. The injection should be given after 
the child has been placed in bed for the night. It is our ob- 
ject to have the oil retained during the night. If a passage of 
the bowels is produced at the time, or if the oil leaks out during the 
night, a smaller quantity should be used. In some of my patients 
I have been able to use but one ounce. In very few, indeed, does 
it cause an evacuation at the time. If there is a tendency to leakage 
a napkin should be w^orn to avoid soiling the bed-linen. If the oil 
is simply placed beyond the internal sphincter, it will rarely be 
retained during the night, or if retained, the results are by no means 
as good as when it is placed in the descending colon. The following 



1 86 GASTRO-ENTERIC DISEASES 

morning, after breakfast, the child is placed on the vessel and kept 
there until a bowel movement results or until fifteen minutes have 
elapsed. In a great many cases in which the constipation has been 
obstinate for months, the bowel will at once be evacuated. When 
this does not occur in fifteen minutes, a glycerin suppository is in- 
serted, which invariably produces an evacuation. This use of the 
suppository, according to my observation, can usually be dispensed 
with in a very few days; the use of the oil, however, may have to be 
continued for several weeks. When the child has had the oil nightly 
and an evacuation the next morning without assistance for two 
weeks, I direct that the oil be omitted for a night and the effect noted. 
If the usual passage occurs after breakfast, the oil is given for five 
nights and then again omitted. If the case progresses satisfactorily 
'the use of the oil is gradually omitted, being given at first every 
second night, then every third, fourth, or fifth night, etc. A con- 
siderable number of cases have been completely relieved in two 
months. In the event of no passage following the omission of the 
oil, its use is continued for two weeks longer, when it is again omitted 
for a night. To illustrate this point the following case is cited : 

Illustrative Case. — A boy three years of age had never had a 
bowel evacuation without drugs, soap enemas, or suppositories since 
birth, and finally these were no longer effective. The mother, 
thoroughly frightened, brought the child to me. Eight months of 
diet and the use of the oil were required before he was entirely 
well. It is now three months since the local treatment was dis- 
continued and the bowel function remains normal. 

The diet with the absence of milk must be continued for 
months after the patient is apparently well, and he must not be 
allowed to pass a single morning without an evacuation at the 
usual time. In assuming the management of one of these cases 
I explain to the mother or nurse that the treatment is not 
pleasant for the child or the attendant, and that it may have to be 
persisted in for weeks, and unless she is willing to carry it out to the 
end, it would better not be undertaken. I assure her, however, 
that with her cooperation, which is usually readily given, the child 
will make a complete recovery. Cases that are slow in responding 
to treatment, I usually give the additional advantage of abdominal 
massage from twenty minutes to one-half hour, before the child is 
placed at stool. The massage should be practised by one skilled 
in the work. 

The above local measures apply particularly to children after 
the eighteenth month. They may be used earlier, however, following 
out the diet along the lines laid down for bottle-fed children who 
suffer from constipation. In very young children a smaller amount 
of oil should be used, never more than two ounces, usually one 
ounce is all that is required. When the oil treatment is under way, 
whatever the age of the patient, laxative drugs should not be given. 



VOMITING 187 



VOMITING 

While vomiting does not constitute a disease in itself, it is a 
condition of such frequency in children, and occurs in such widely 
varying circumstances, that any work relating to diseases of children 
would be incomplete without its consideration. 

The most frequent causes of vomiting depend solely upon the 
functions of the stomach. When the stomach is overfilled, vomiting 
may result. When substances suffi.ciently irritating come in contact 
with its lining mucous membrane, whether they are swallowed as 
such or whether produced by some process of fermentation or by 
some other change in the stomach contents, they are ejected. When 
there is an involvement of an inflammatory nature of the mucous 
membrane of the stomach, whether acute or chronic in character, 
the stomach becomes intolerant of the blandest of fluids. Another 
condition involving the structure of the stomach, but only occasionally 
seen in children, is ulceration, which is usually multiple. I have 
made autopsies upon four such cases. In them, vomiting was the 
prominent, in fact the only, symptom. 

Dilatation of the Stomach. — In this condition the food does not 
pass into the intestine but remains in the stomach and undergoes 
changes which produce sufficient irritation to cause vomiting. 

Pyloric Stenosis. — In pyloric stenosis the food is prevented by 
the narrow pyloric opening from passing into the intestine; one 
feeding follows another, the stomach becomes overloaded, and, by 
reason of fermentative change in the residue, sufiicient irritation 
is produced, in connection with the spasmodic contractions of the 
stomach peculiar to the condition, to induce vomiting. 

Causes Remote from the Stomach. — In intestinal obstruction, 
whether due to intussusception, volvulus, peritonitis, or impacted 
feces, vomiting is an invariable accompaniment, continuing at irreg- 
ular intervals until the obstruction is relieved or until the child dies. 

The Acute Infectious Diseases. — The exanthemata and lobar 
pneumonia are very apt to be ushered in by vomiting if the onset 
is sudden and intense. In appendicitis in children, vomiting is 
usually one of the early symptoms ; so also in the different forms of 
meningitis, vomiting is often an early symptom, and may continue 
persistently during the first few days of the illness. In nephritis, 
with uremia, vomiting is usually present. Vomiting may be caused 
by fright, by shock, or by a strain of any nature, as in whooping- 
cough, or it ma}^ be of a purely nervous origin. 

Illustrative Case. — A few years ago I had a most unusual and in- 
teresting case. The patient was a girl four years old, pale and thin. 
The history was that of vomiting for more than a year, which had 
begun with rather a protracted, badly managed attack of indigestion. 
At first there would be but one or two attacks a day. Later they 



1 88 GASTRO-KNTKRIC DISEASES 

became more frequent, and for a few weeks before coming to me, the 
vomiting had occurred at the table with nearly every meal, before 
the meal was completed. The mother was most anxious and appre- 
hensive regarding the child's condition. She was always with her, 
always fed her, and always worried constantly throughout the meal, 
fearing an attack of vomiting. Using the most thorough means of ex- 
amination of the stomach, I failed to find anything wrong with it. 
After observing the case for some days it occurred to me that the 
presence of the apprehensive mother, in whose mind the condition 
of the child and the vomiting were uppermost, might be a factor in 
causing the vomiting. I accordingly directed that the child take her 
meals in the kitchen with the maid, and that the matter of 
vomiting should not be mentioned. The mother was directed not 
to come in contact with the child in any way during the meal. I 
was much gratified and not a little surprised when the vomiting 
promptly ceased. After a few months of dining with the maid the 
latter was taken ill, and the mother for one day attended to the 
feeding. Again the child vomited as before. 

The management of the different types of vomiting will be 
referred to in the consideration of the various diseases with which 
it is associated. 

ACUTE GASTRITIS AND ACUTE GASTRIC INDIGESTION 

Not a little confusion exists as to the differentiation of acute 
gastritis and acute gastric indigestion. Cases of gastric indigestion 
are often diagnosed as gastritis. In fact, acute gastritis in children 
is a very rare condition, while acute gastric indigestion is very 
common. Acute gastritis in the young is usually due to the ingestion 
of drugs, corrosive or irritant in character. Food given, unsuitable 
in character or quantity, or food which may have undergone chemical 
or bacterial change, may produce pronounced vomiting, usually 
transient in character. Inflammation of the mucous membrane of 
the stomach may be produced in this way, but according to autopsy 
findings it is most unusual. Acute gastric indigestion is manifested 
in sudden repeated vomiting, often with fever, and always with 
prostration. 

Cases of persistent vomiting which are often diagnosed as gas- 
tritis not infrequently prove to be of cerebral or uremic origin, or 
they are due to some form of intestinal obstruction. 

Autopsies on infants dying from acute gastro-enteric diseases, 
such as cholera infantum, rarely show any stomach lesion, although 
there may have been persistent vomiting for two or three days. 

Treatment. — A high enema should always be given as the initial 
treatment in any illness of any nature in which there is acute vom- 
iting with an absence of free bowel action. If the vomiting is 
continued, the management of the case, regardless of the exciting 



ACUTE GASTRITIS AND ACUTE GASTRIC INDIGESTION 1 89 

cause, is to wash out the stomach at least once and to give no food by 
mouth. If the case is of more than twelve hours' duration in infants 
and twenty-four hours' in older children, colon flushings should be 
carried out to supply fluids to the organism (page 210). 

Diet. — After twelve or twenty-four hours' abstinence from food, 
small quantities of water may be given tentatively, if the child 
craves it, or some very weak food. Whey, milk, barley-water, weak 
tea, chicken or mutton broth, may be tried in teaspoonful doses 
every half hour. Usually cold foods will be retained better than 
those that are heated. If the food or water is rejected a further 
stomach rest of from eight to twelve hours may be ordered, before 
the feeding is resumed. 

Treatment of Protracted Cases. — In the protracted cases the 
stomach should be washed, at least once daily, with a 5 percent 
solution of bicarbonate of soda. It is never wise, in the event of 
vomiting, to attempt forced feeding, as nothing will be gained; in 
fact, the vomiting may be continued indefinitely, and chronic gastric 
indigestion established, as a result of injudicious attempts at feeding. 
For the persistent vomiting of infants, gavage (page 141) may also 
be used. I have employed this successfully in a great many cases 
of persistent gastric indigestion with vomiting. A food which is 
rejected when swallowed, will oftentimes be retained when put into 
the stomach through a tube. If nourishment cannot be retained 
after thirty-six hours, when given by the natural method or by 
gavage, it is best to begin feeding by the bowel, using completely 
peptonized milk, at intervals of from six to eight hours, in quantities 
of from two to four ounces for young infants and from six to twelve 
ounces for children from eight to ten years of age. Applications of 
heat or counter-irritation over the stomach area have been of very 
little service. I have used mustard leaves from time to time, but 
have never been impressed with their A^alue. Drugs were better 
omitted. I have treated hundreds of these cases of acute indigestion 
with different means of medication, including calomel, small doses of 
ipecac, oxalate of cerium, opium, etc., and have been far more 
impressed with their uselessness than with their beneficial influence. 
Drugs oftentimes get credit to which they are not entitled for the 
improvement of the patient. A child has an acute attack of indiges- 
tion with repeated vomiting. He is, perhaps, given an enema, his 
food is stopped, a certain drug is given in small quantities of water, 
and he recovers, and the drug gets the credit. He probablv would 
have recovered more quickly without the drug. As a rule, drugs, 
or even the use of a small quantity of water, when given early, will 
prolong the attack. 

An enema, the recumbent position, and abstinence fromi food, 
with fluids such as normal salt solution, or nourishment by the 
bowel, have given me my best results. When the child craves food, 



I90 GASTRO-ENTERIC DISEASES 

and asks for water after an abstinence of several hours, it may be 
tried, but the fact that he asks for it is by no means a guarantee that 
it will be retained. 

Treatment of Persistent Vomiting. — In pronounced, persistent 
vomiting, morphin hypodermatically may be required. The morphin 
should be guarded by atropin and given in doses of J^- to -j^ grain for 
a child one year old, to -f-^ of a grain for a child of from eight to 
twelve years old. The relation of the dose of morphin to that of 
the atropin should be as i to ^V- Thus, a child who is given -^-^ 
grain morphin should have combined with it g-J-Q- grain atropin; 
with -j^ grain morphin there should be -^-^ grain atropin. 

It will rarely be necessary to repeat the morphin more than once, 
two injections being given at intervals of from four to six hours. 
In all cases the usual feedings must gradually be resumed. After 
trying different foods it will soon be learned which will best be re- 
tained. 

CHRONIC GASTRIC INDIGESTION; CHRONIC GASTRITIS 

Chronic gastritis is seen most frequently in comparatively young 
children, and is often associated with, or is a cause of, marasmus 
and malnutrition. Vomiting and regurgitation of food are the 
predominant acute manifestations of the disorder. The condition 
is almost invariably a result of slight but persistent errors in feed- 
ing — errors too small to make the child violently ill, but sufficient 
to keep the stomach in a constant state of unrest. 

Treatment. — The management consists in daily stomach- wash- 
ings, sometimes for a long period, and an adaptation of the food to 
the child's digestive capacity (page io6). While there is no one way 
of feeding these cases, a food of greatly reduced strength must 
always be given, particularly when cow's milk is used. As a rule, 
these children have a low-fat capacity; not more than 1.5 percent 
can usually be taken. Sugar is also badly borne by many of these 
infants and must be given in reduced strength — from 3 to 4 percent 
only. Usually the proteids are fairly well taken care of if the func- 
tion of the stomach is not compromised by too much fat and sugar. 
In children under nine months of age, a wet-nurse may help solve 
the problem. In beginning with the wet-nurse, however, the child 
should not be allowed to get over one or two ounces at a nursing, 
lest the fat in the milk continue the trouble. The remainder of 
the feeding is given by the bottle. Granum-water or barley-water 
No. I (see page 129) may be used in quantity sufficient to bring up 
the amount to the number of ounces required. 

Dilatation of the stomach is usually present and motor inactivity 
necessitates stomach- washing, which may be required for several 
months at gradually increasing inten^als. Details of the treatment, 
which are largely matters of feeding, would necessitate a repetition 



LAVAGE — STOMACH -WASHING I9I 

of what has been said in the chapter on Malnutrition, Marasmus, 
and Food Adaptation, to which the reader is referred. 

LAVAGE— STOMACH-WASHING 

To Seibert, of New York, is due the credit of first cahing attention 
in this country to the value of stomach-washing. Its use was soon 
appreciated by pediatricians generally, and at the present time it 
is an indispensable therapeutic measure with those w^ho are actively 
engaged in children's hospitals, in out-patient or in private work 
among children. In the vomiting of children, whether due to an 
acute gastro-enteric infection, a chronic indigestion, or a subacute 
attack of chronic gastritis, it is equally valuable. The dangers of 
stomach-washing can be said to be practically nil. A colleague a 
few years ago, while washing the stomach of a child two years of age, 
turned away for a moment, when suddenly the struggling child dis- 
connected the tube from the glass connecting-rod and swallowed it. 
Attempts at its removal through the bowel were unsuccessful; 
gastrostomy was performed, the tube removed, and the child recov- 
ered. This is the only accident of any kind I have ever known 
during stomach-washing. 

The Operation. — For lavage, the child is easiest handled when its 
arms are pinned to its sides by a towel passing around the body. 
It may rest on its back in a crib, or sit upright on the lap of the 
nurse or mother (Fig. 20). The clean left index-finger of the phy- 
sician is placed upon the base of the patient's tongue. The tube, 
moistened with the fluid to be used in the washing, not with oil, is 
passed down over the base of the tongue into the esophagus. It is 
practically impossible to pass it into the larynx. I have washed 
the stomachs of many hundred children and the introduction of 
the tube has never been attended with difficulty. When the tube 
has entered the esophagus, it should be passed rapidly into the 
stomach. At least nine inches of the tube will be required to 
reach the lower portion of the stomach. At first the child will 
cough, retch, and become red in the face, but this need cause no 
alarm. He will soon cry and begin to breathe regularly. When 
the tube is in position, the funnel should be held the length of the 
tube, two and one-half to three feet, above the patient's body, and 
the water, w^hich should first be boiled, poured into it. At first the 
water may remain stationary in the funnel, owing to the pressure 
of air in the stomach and the straining of the child. When the 
child relaxes or the air escapes, being forced upward through the 
water, the water will pass rapidly into the stomach. 

The apparatus described under Gavage (page 141, Fig. 17) is 
used. It should always be boiled before using. If much mucus is 
present, a i percent solution of boric acid or borax may be used. 
The amount introduced into the stomach at one time varies 



192 



GASTRO-ENTKRIC DISEASES 



with the age of the child. In a baby of one week, one ounce 
may be used; at six weeks, two ounces; at six months, from four 
to six ounces. It is rarely advisable to introduce more than six 
ounces at one time. The fluid is allowed to run into the stomach 
and is then siphoned out by lowering the funnel, the process being 




.ai 



Fig. 20.— Lavage. 



repeated until the fluid returns perfectly clear. From one to two 
pints of water may be necessary to complete the washing. 

Indications. — It is rarely necessary to wash the stomach oftener 
than twice in twenty-four hours. Ordinarily, in the acute vomit- 
ing cases, one washing daily for four or five days will answer. In 
cases of chronic indigestion with regurgitation, the washing will be 



LAVAGE — STOMACH- WASHING 193 

needed less frequently. Here, once a day, or once every second or 
third day, will answer. 

The following is frequently the history of a case of chronic indiges- 
tion with vomiting: There has been for several weeks, vomiting of 
food and mucus, two or three times daily. The stomach was washed, 
the child carefully dieted with a plain barley-water or a weak milk 
mixture, and no vomiting had occurred for perhaps twelve, twenty- 
four, thirty-six, or forty-eight hours, when the regurgitation or 
vomiting again commenced as before. In such a case it will soon 
be learned how frequently the washings should be repeated in 
order to control the vomiting. A recent patient represents my 
management: A child six months old suffering from malnutrition 
had a history of persistent vomiting after each feeding. A greater 
part of the food taken was lost. What was not vomited was digested 
imperfecth^ as was shown by the stools. The stomach was washed 
and a large quantity of thick mucus and curds removed. The child 
was placed on a barley-water diet. There was no vomiting for three 
feedings and then only a small quantity of barley-water was thrown 
off. After three days, with daily washings, the vomiting entirely 
subsided. The child was put on a weak milk mixture, one-fifth 
milk and four-fifths barley-water, and no vomiting of moment 
resulted. The food was carefully strengthened, and although in 
two weeks the vomiting had entirely ceased, the washings were 
continued at intervals of two or three days for a month, until the 
water siphoned out was free from mucus. In severe cases of chronic 
indigestion the washings at intervals of two or three days may be 
continued with advantage for several months. 

It must be remembered that in these chronic cases of indigestion, 
the patient is ill through abuse of the stomach — usually because too 
strong food has been given, or too much of a suitable food was 
given at too frequent inter^'-als. As important, then, as the stom- 
ach-washing, is the placing of a child on a food suited to its diges- 
tive capacity. Lavage is of little service if the bad feeding continues. 

The field of usefulness of lavage is not entirely confined to 
vomiting cases. Children with indifferent appetite and limited 
food capacity, without vomiting, are often greatlv benefited by 
it. A story frequently heard in our consulting room is as follows: 
Food is taken without relish. The child must be coaxed to eat. 
There is loss of appetite, usually the result of improper food or 
faulty feeding methods. Some patients are absolutely indifferent 
to food; many refuse it altogether. In this class of patients a 
stomach-washing once a day will often be followed by a surprising 
improvement in the appetite. I know of no better appetizer for 
many of these pitiful looking babes. In not a few instances I have 
been surprised at the large amount of mucus removed from the stom- 
ach of one of these children in whom there had been no vomiting 



194 gastro-ente:ric diseases 

whatever, which teaches us that there may be, in infants, stomach 
disorders of considerable importance without vomiting or, in fact, 
without any other symptom than loss of appetite and malnutrition. 

HEMORRHAGE FROM THE STOMACH; VOMITING OF BLOOD 

Excluding hematemesis in the newly born, the vomiting of blood 
by infants has been due, in my experience, to ulceration of the 
stomach (page 195), to purpura fulminans (Henoch's), or to acciden- 
tal causes. In two of my proved cases, extensive ulceration of the 
stomach was found at autopsy. A boy six years of age died on the 
third day with purpura fulminans. There were profuse hemorrhages 
from the stomach, from the mucous surfaces, and under the skin. 
Ulceration of the stomach is usually associated with marked gastric 
disturbance, such as is seen in gastritis and in the different forms of 
malnutrition. Accidental sources include the swallowing of blood, 
which may take place as the result of a nasal hemorrhage or from 
a blow or fall causing injury to the nose or mouth or from the presence 
of a foreign body in one of the nostrils. Injury to the pharynx 
also may be followed by hemorrhage sufficient to cause vomiting, 
if the blood is swallowed. A case of hematemesis in a well-nourished 
breast-fed infant five months of age, gave me a great deal of anxiety. 
The vomiting of blood continued for several da^^s without the 
slightest evidence as to its source. It occurred two or three times 
a day, usually shortly after nursing, the quantity of blood being 
especially large after the early morning nursing. There were no 
cracks or fissures in the mother's nipples, nor could blood be made 
to exude from any portion of the nipples on reasonably strong pres- 
sure. I concluded, nevertheless, that its source must be the breast, 
and applied a breast-pump, making use of as strong suction as 
possible, and obtained milk with a large mixture of blood. Evi- 
dently there had been a rupture of some of the smaller blood-vessels 
in the gland behind the nipple. At the first nursing, the child was 
very hungry and tugged vigorously at the breast, which doubtless 
explains why the early morning vomiting showed the most blood. 

DILATATION OF THE STOMACH 

In children of any age the stomach capacity may be found 
greatly increased. Bottle-fed infants under one year of age furnish 
the most of the cases. 

In the absence of pyloric stenosis (page 196), the persistent 
feeding of too large quantities of food is the cause. It is not at 
all infrequent, in cases of malnutrition and athrepsia, to find the 
patients taking at every feeding from two to three ounces above 
the normal stomach capacity for children of their size and weight. 
Infants with dilated stomachs almost invariably suffer from in- 
digestion, usually with the vomiting of milk curds and mucus,. 



ULCERATION OF THE STOMACH 1 95 

the vomiting generally taking place a considerable time after the 
feeding. 

Oftentimes, in these cases, the nourishment that has been given 
is of the proper strength, and all that will be required is to reduce 
the quantity allowed and perhaps increase the frequency of the 
feedings. The stomach should be washed daily, if the child resists 
the simple reduction in the amount of fluid. Particularly is the 
stomach to be washed, if there is a tendency to fermentation in 
the stomach-contents. The food should contain a low fat and a 
moderate amount of sugar. A reasonably high proteid may usually 
be given. Because of the tendency to fermentation, these cases 
do badly on the gruel diluents also, which, if they have formed a part 
of the child's diet, are to be discontinued. Small doses of bismuth 
subnitrate — five grains, with two grains bicarbonate of soda, two 
hours after each feeding — have a decidedly beneficial effect. Hy- 
drochloric acid should not be given and pepsin is unnecessary. 

Dilatation of the stomach, after the eighteenth month, will be 
found due to the same cause of overfeeding, or the condition may 
have been brought forward from earlier infancy. At this age, it is 
seen most frequently in children who take large quantities of milk 
with their regular meals. Milk being no longer a necessary part of 
the diet, it may now be replaced by more concentrated food, such as 
meat, eggs, and cereals in moderate amount. Not over four ounces 
of fluid should be given with any one meal. The habit of drinking 
with meals is best broken by encouraging the child to drink between 
meals. One hour before each feeding he should be given eight 
ounces of water. It should be given cool, not cold, at a tempera- 
ture of from 50° to 60° F., and should be drunk slowly. It is con- 
sidered particularly necessary to give water one -half hour before the 
first meal of the day. In my estimation it is equally important to 
give it before each meal. 

ULCERATION OF THE STOMACH 

In a large autopsy experience among infants and young children, 
I have as yet to see a perforating ulcer, either tuberculous or other- 
wise. In fact, aside from those of the newly born I have seen at 
autopsy only two cases of ulceration. In three other cases, the 
diagnosis of ulceration was made because of hematemesis. In one, 
a child one month old, blood was repeatedly vomited. The child 
bled to death. At autopsy about two ounces of coagulated blood 
were found in the stomach. The mucous membrane of the stomach 
was the seat of many ulcers varying in size, but none exceeding 
one-sixteenth of an inch in diameter. Another patient, three months 
old, had chronic gastro-enteritis with occasional vomiting of blood. 
The child died from exhaustion, the autopsy showing multiple small 
ulcers in the mucous membrane of the stomach. That ulcerations, 
even of a mild degree, play any great part in the digestive disorders 



196 GASTRO-KNTERIC DISEASES 

of infants and young children is disproved by the infrequency of 
the lesion at autopsy, in children dying from gastro-enteric or 
other diseases. 

In treating cases of gastric disorders by stomach-washing, it is 
comparatively rare that blood is found in the water siphoned off. 
At rare intervals the water may be tinged with blood, but the 
washings invariably should be continued in spite of this, as I have 
never known any hemorrhage of moment to follow. The blood 
which appears under these conditions is doubtless from the capil- 
laries of the congested mucous surface, distended as a result of strain. 
Although such cases are rare, one never knows but that his next 
case will be one of them. 

Treatment. — In the event of persistent vomiting of blood of 
small or large amount which cannot otherwise be accounted for, it 
should be regarded as coming from the walls of the stomach. Under 
these conditions, food by means of the stomach should be discon- 
tinued and the nutrient enema (page 145) should be brought into use. 
Bromid and chloral, or stimulants if necessary, may thus be given 
with the food. Calcium lactate should be given in two-grain doses 
and continued for twelve hours after the vomiting ceases. After 
thirty-six hours water may be given in small amounts, and the giving 
of the usual milk mixture diluted one -half, in small quantities, two 
or three ounces, may also be commenced. The normal diet should 
not be resumed in less than a week, even with an entire absence of 
vomiting during this period. 

CONGENITAL PYLORIC STENOSIS 

In the chapter on persistent vomiting it will be found that 
stenosis of the pylorus is mentioned as one of the possible causative 
factors of repeated vomiting. The condition of hypertrophy of 
the pyloric end of the stomach with narrowing of the outlet is 
practically always of congenital origin, even though the symptoms of 
vomiting may not appear for three or four weeks after birth. 

That a stenosis exists, is suggested by the character of the 
vomiting. Two factors are at work in these cases, the spasm and 
the stenosis. The time of the occurrence of the vomiting suggests 
also the seat of the trouble. Three or four nursings or feedings may 
be taken and retained, when suddenly a considerable portion of these 
feedings is ejected. The vomiting differs from that of gastric disor- 
der, in that it is expulsive, one forcible ejection taking place which 
removes all or a portion of the stomach contents. There usually is no 
associated diarrhea or other evidence of intestinal involvement, aside 
from constipation, this being in marked contrast with the ordinary 
acute digestive derangements of infancy. In two hours after feeding, 
the stomach of a nursing infant should be practically empty. The 
introduction of a stomach-tube in a case of stenosis will show that a 
greater part or all of the food is still in the stomach if it has not 



PREVENTION OF ACUTE INTESTINAL DISEASES OF SUMMER 1 97 

previously been vomited. The "stomach wave" is one of the 
characteristic signs of the condition. Beginning at the cardiac end, 
the contractions of the stomach produce a wave-hke movement of 
the abdominal wall, as though a ball were moving under it, making a 
pressure on the parietes. The ball-like movement is further sug- 
gested by the gradual relaxation of the portion of the abdominal 
wall first contracted, which leaves the parietes as before. The 
contraction continues until the pylorus is reached. Persistent vom- 
iting, expulsive in character, in a newly born infant, associated 
with scanty, well-digested stools, should always suggest to our mind 
the possibility of pyloric stenosis. 

Treatment. — The only treatment, in the great majority of in- 
stances, is operation. In a gastro-enterostomy, considering the 
age of the patient and the usual emaciated condition, the out- 
look is not promising, the mortality being necessarily high. A 
few cases in which there is but little hypertrophy and moderate 
stenosis recover without operation. Before resorting to operation, 
there must be the strongest evidence that the child will not recover 
without it, as operation should be a last resort. This should be de- 
cided as early as possible, before there is a loss of too much strength 
and power of resistance. By weighing the stripped patient daily, it 
is not difficult satisfactorily to convince ourselves of the advisability 
of delay. If the child loses weight day after day, operation by gastro- 
enterostomy or divulsion^ should not be delayed. If the weight 
is stationar}^ or if but a slight gain is made, temporizing may be 
permitted, with the hope that greater improvement will follow. 
The patient should be given the advantage of the best nourishment 
possible — human milk. If the mother cannot nurse the patient, a 
wet-nurse should be secured. The stomach should be washed at 
least once daily to remove the food residue. 

PREVENTION OF THE ACUTE INTESTINAL DISEASES 
OF SUMMER 

Preventive medicine, so called, is at the present time engaging 
the attention of the best medical minds. The acute intestinal 
diseases of summer, with their large infant mortaUty, offer a better 
field for Hfe-saving measures than does any other department of 
pediatrics. 

Potent etiologic factors in summer diarrhea are unfavorable 
cHmate and unfavorable environment. In the class which furnishes 
the largest mortality, climate cannot be changed for a sufficient num- 
ber to exert any great influence on the general mortahty. Through 
education the environment may be radically improved, but it can- 
not be changed. The hot months come and the tenement child must 

^ Dr. Geo. F. Still, of London, who has had a large experience with different 
operative methods, advises divulsion. 



198 GASTRO-ENTERIC DISEASES 

remain at home. Excursions and outings of various kinds are valu- 
able in a small way to comparatively few, as the child must return 
to the tenement home at night or after a few days' absence, so that 
in our consideration of this class of patients in large cities we must 
accept unfavorable environment and hot weather — in other words, 
we must treat these cases in their homes. Those more fortunately 
situated, who can have the advantage of the country and intelligent 
care, are proportionately less liable to diarrheal diseases. Other 
than climate and environment, the determining etio logic factors 
among all classes are: first, a disordered gastro-enteric tract; 
second, infected food; third, faulty feeding methods; fourth, an 
absence of appreciation on the part of the parents and physicians 
of the fact that an attack of diarrhea or vomiting, or even a green 
undigested stool, occurring in an infant under eighteen months of 
age during hot weather, is to be looked upon, as a serious matter 
requiring prompt attention. 

Children as well as adults are frequently exposed to disease from 
sources of which they are ignorant, because their power of resist- 
ance is insufficient for their protection. With milk, the most readily 
infected of all nutritional substances, as the chief article of diet, 
it may safely be assumed that few infants pass through the heated 
term without having been subjected repeatedly to infection from 
bacteria sufficient to produce grave illness. An infant's best safe- 
guard against intestinal infection is a strongly resistant gut, which 
is best secured by the absence of digestive disturbances at all 
seasons of the year. Feeding and intelligent management generally 
throughout the year has, consequently, a decided bearing upon sum- 
mer mortahty from intestinal diseases. 

Seventeen years ago, at the commencement of my junior service 
on the house staff at the Country Branch of the New York Infant 
Asylum, I gained my first knowledge of summer diarrhea. While 
making rounds early one morning in June, the matter of summer 
mortality among the infant population was being discussed with the 
resident physician, the late Dr. Clarence E. Kimball. I asked why 
they had such a large summer mortality in an institution situated, as 
it was, at a considerable elevation, in the open country, constructed 
on the cottage and dormitory plan, with the additional advantage 
of good milk, favorable environment, good nursing, and competent 
medical attendance. His reply was: "Take your pencil and write 
as we go through the wards the names of the children I indicate." 
I did so, and, at the completion of the round, he directed me to 
keep the Hst of thirty names, saying that these children probably 
would not survive the summer. Seeking an explanation I remarked 
that they were not delicate or athreptic. "No," he replied, "they 
look well, but they have foohsh, ignorant mothers, and susceptible 
intestines. They have had frequent attacks of diarrhea and indiges- 



PREVENTIOX OF ACUTE INTESTINAL DISEASES OF SUMMER 199 

tion during the winter and spring. The mothers steal food from 
their own table and give it to the children when the orderlies and 
nurses are out of the wards. These children have but little intestinal 
resistance, and will give us our first fatal diarrheal cases when the 
hot weather comes." I kept my list and found that the accuracy of 
his prediction w^as startling. But four of the children named sur- 
vived the summer. 

Since that time I have had abundant opportunity to observe 
that the children who have had frequent attacks of intestinal indiges- 
tion during the colder months furnish our severe cases during the 
summer. A most important feature, then, in prophylaxis is to 
teach the mother how to feed and care for the child all the year round, 
and thus, by keeping well, he maintains a high grade of intestinal 
resistance. 

Etiology. — The principal immediate etiologic factor of the dis- 
ease which we have under consideration is an infection of the gastro- 
enteric contents by bacteria. The infecting elements are usually 
introduced by means of contaminated food and unclean feeding 
apparatus. 

New York City Conditions and How to Correct Them. — For the 
well-to-do, we have high-priced dairies whose product sells from 
fifteen to eighteen cents a quart. For others, we have what is 
known as "certified milk," produced under the supervision of a 
committee of medical men, Vv^hich retails at twelve cents a quart. 
Obviously, the majority of our infant population is not fed on these 
milks. The Straus Laboratories, which supply safe sterilized milk 
in New York City, are able to furnish it to but a small proportion 
of the tenement population. The other milk, the so-called "market 
milk," supplies nutrition for an immense majority of the infants of 
the poorer classes. This milk has been greatly improved of late 
through the efforts of the medical profession and the New York 
Health Department ; but the matter of the regulation of milk pro- 
duction and sale is a large one, and the powers of the authorities 
are Hmited. The majority of our infant population, then, is fed on 
milk which, for them, is not a safe food ; and it is among these infants 
that the large mortality occurs, and will continue in spite of seashore 
visits, daily excursions, and the efforts of the summer corps of 
Health Department physicians. It will continue until every large 
municipality, such as New York City, shall establish milk depots and 
ice stations where safe milk, and ice to keep it safe, may be obtained 
at a nominal cost, or free, if the parents are not able to pay for 
it. A visiting physician for these people is not absolutely necessary, 
nor. is a visiting trained nurse, — both are expensive luxuries; but 
what is necessary is the appointment for a given district of women 
with just plain common sense to teach the uninformed mothers, 
who are doing their best according to the light they have, the 



200 GASTRO-KNTERIC DISEASES 

simple details of the infant's care, easily carried out when they know 
how, but so rarely done because they do not know how. 

Dispensary Rules of Universal Application. — At the out-patient 
department of the Babies' Hospital and the New York Polyclinic, 
I have had abundant opportunity to come into close contact with 
a great many tenement mothers and tenement children. At these 
institutions we have a clientele fairly regular in attendance, year 
after year; for as one baby after another appears in the family, 
they are brought to us for treatment. At these dispensaries we 
have a surprisingly low summer diarrhea mortality, because we 
teach the mothers how to feed and care for their children all the 
year round. They are taught the value of fresh air, the use of 
boiled water as a beverage, and the benefits of frequent spongings 
on hot days. Both private and dispensary mothers whose children 
are under my care are given pamphlets of instruction and also oral 
teaching bearing on these points, and particularly as to the care 
of the feeding-bottle and the milk. In case special articles of diet 
are to be given, they are taught how to prepare them. Written 
.directions are always given covering the point ; nothing is left to the 
memory. Each mother and nurse has it impressed upon her that she 
must wash her hands in soap and water before touching the baby's 
food or feeding apparatus for any purpose, and that there must be 
a covered vessel in which the soiled napkins are to be kept until 
washed. At the first sign of intestinal derangement, regardless of 
the season of the year, they are taught to stop the milk at once, to 
give instead a cereal water, such as barley-water or rice-water, and 
a dose of castor oil. It is impressed upon them that, in winter as 
well as summer, a green, watery stool means that the baby is ill 
and needs treatment. When the mother learns the above lesson for 
December, January, and March, she will not forget it in July. 
Furthermore, as a result of the immediate correction of a child's di- 
gestive disorder during the winter months, we have a much less 
fertile field for pathogenic bacteria during the summer. 

Prompt Treatment Essential. — Comparatively few cases of in- 
testinal diseases have pronounced toxic symptoms at the outset. 
At first there are evidences of a mild infection only. There may 
be vomiting, with several green, watery stools, with a slight ele- 
vation of temperature, or the symptoms may be still more mild 
— only one or two loose, green defecations. Prompt treatment 
at this time, even in a crowded tenement, usually means prompt 
recovery. When treatment is delayed, when the administration of 
milk is continued, severe toxic symptoms and intestinal lesions are 
almost invariably the result. 

New York City Experiments. — An interesting demonstration of 
what may be accompHshed by proper care was made under the direc- 
tion of Dr. WiUiam H. Park, of the New York Health Department, 



PREVENTION OF ACUTE INTESTINAL DISEASES OF SUMMER 20I 

during the summer of 1902. Fifty tenement children, ranging from 
three to nine months of age, were selected for the experiment. These 
children were all fed on the Straus milk. They were visited two or 
three times a week by physicians especially assigned to them. The 
mothers were carefully instructed as to the care of the milk, the feed- 
ing apparatus, and in other necessary details. With the first signs of 
illness, the milk was to be stopped, the physician notified, and suit- 
able treatment instituted. Among these fifty tenement children, all 
under one year of age, all bottle-fed, selected at random, there was 
not one death during the summer. This valuable observ'ation bears 
out my contention that the deaths of summer diarrhea among 
tenement children may be greatly reduced by the use of good milk 
given under proper supervision, supplemented by prompt and compe- 
tent medical care at the first sign of illness. Perhaps in i percent 
of the cases of summer diarrhea a very severe direct infection is 
evident, and the condition of the patient very grave from the onset. 
In the remainder the invasion is gradual; and, if the w^arnings are 
heeded, the illness will usually terminate quickly in recovery. 

How to Secure Good Milk. — To those of my patients of the bet- 
ter class who go to the country for the summer, and who have 
cows of their own in order to control their milk-supply, I give the 
following directions: Before milking, the udders and belly of the 
cow should be wiped with a damp cloth to remove clinging par- 
ticles of dirt. It is in these droppings containing manure that 
the most dangerous forms of bacteria of decomposition enter the 
milk. The milker should wash his hands before milking. The 
first few jets of milk, coming from the ducts near the openings, are 
apt to be swarming with bacteria, and are therefore discarded. 
Immediately after the milking, the milk should be strained through 
several thicknesses of cheese-cloth, or through absorbent cotton, 
into an ordinary milk bottle, which is at once placed in a pail 
of cracked ice. Such simple care as this, even on an ordinary farm, 
gives a very low bacteria count. As may readily be seen, it is 
attended with very little trouble and expense. Different dairies 
throughout the country, which are located near my patients for the 
summer, meet the above requirements, for which they receive an 
extra compensation of five or six cents a quart. 

The Necessity for Education. — It will be seen from the foregoing 
that the suggestions we have offered are all included under the one 
general heading of Education. The mother must be educated how 
to live, how to care for the baby, how to clothe him and bathe him 
during the summer. It must be impressed upon her that he needs all 
the fresh air available. She must be educated to the point of know- 
ing what to do at the first sign of threatened disease. Municipalities 
must be educated to appreciate their responsibility as factors, nega- 
tive or positive, in the summer mortality. The farmer must be 



202 GASTRO-ENTERIC DISEASES 

educated as to how to produce safe milk, and the consumer must be 
educated to appreciate its value and pay for it. Above all others, 
the physician must be educated along these lines so as to be able 
to teach the mothers how to do the right thing as to the care of 
her children all the year round. 

ACUTE GASTRO-ENTERIC INFECTION; CHOLERA INFANTUM; 
GASTRO-ENTERIC INTOXICATION 

This form of infection, while acute in character, is rarely of 
primary origin. It is usually preceded by a disordered gastro-enteric 
digestion. The onset of the urgent symptoms, however, is usually 
most pronounced, the child being taken suddenly with persistent 
vomiting, retching, and the passing of large watery stools, usually 
greenish in color. The prostration is extreme, the respiration be- 
comes shallow, the eyes sunken, the skin ashen in color, the pulse 
soft and very rapid. The temperature may be high — 105° F. or 
106° F. — or it may never rise above the normal. The low-tempera- 
ture cases with symptoms of pronounced prostration give us our 
most hopeless cases. The system is so overwhelmed by the in- 
fection that the patient is unable to react. I have seen infants die 
in twelve hours after the onset of the active symptoms. From this 
extreme degree of infection cases vary in severity, to one who is 
taken with a sharp attack of vomiting and high fever. Occurring 
coincident with or following within a few hours, there are several 
large watery stools. The fever soon subsides. The stomach is 
washed, the milk is withheld, boiled water or weak barley-water or 
rice-water No. i (see formulary) is given, and the child is well in a 
day or two. 

Treatment. — The management of the case depends entirely upon 
the nature and urgency of the symptoms. In the acute choleraic 
cases with repeated vomiting, severe toxemia, retching, and profuse 
watery stools, stomach-washing and bowel irrigations are useless 
procedures. What we must do is to support the patient and aid 
him to bear the poison he has to contend with. If the temperature 
is high with a dry, hot skin, a cool pack to the trunk, 85° to 90° F., 
which is moistened with water at this temperature every half hour, 
will often control the pyrexia. If the feet are cold, hot-water bottles 
should be brought into use. If the temperature is below normal, 
and the peripheral circulation poor, as indicated by a leaden hue of 
the skin, a hot-water bath at 108° F. for five minutes will always 
be of service. The bath may be repeated at half -hour intervals. 
Other than this, the immediate treatment calls for hypodermic 
stimulation and sedatives. The administration by mouth of food or 
stimulants should not be attempted. Tincture of strophanthus and 
brandy, hypodermatically, have answered me well in these cases. 
Twenty drops of brandy with one drop of the tincture of strophanthus 



ACUTE GASTRO-ENTERIC INFECTION 203 

mav be given at interv^als of one, two, three, or four hours, depending 
upon the urgency of the case. A combination of morphin and 
atropin may be used in cases with persistent vomiting, with a view 
to controlHng the attempts at vomiting which exhaust the patient, 
and also to diminish the continuous loss of the fluids of the body, 
from the repeated large watery stools. Obviously morphin should 
not be given unless this condition exists. For a child one year of 
age Jq- grain of morphin is given with ^^ grain atropin, repeated as 
required, not oftener than once in tw^o hours. iVfter the first year 
-3^-Q- grain of morphin may be given as an initial dose. Beneficial 
effects from the morphin will be noted in a diminution both of the 
number of stools and of the vomiting. In milder cases of infection, 
in which the vomiting and the stools are less frequent, a different 
course is to be pursued. In these cases there should be an abstinence 
from food, boiled water being given if the child can retain it. If 
vomiting persists, the water should be discontinued. The stomach 
should be washed at least once daily and the colon irrigated. If 
the irrigation brings away mucus and fecal matter, it should be 
repeated, at intervals of from eight to twelve hours. The child 
should never be disturbed for this purpose if the intestine con- 
tinues to empty itself at frequent intervals. A reduction in the 
temperature, a cessation of the vomiting, and a diminution of the 
number and improvement in the character of the stools tell us 
whether or not the case is doing well and determine the further 
treatment, after the initial dose of castor oil or calomel has been given. 
As a rule, the milder type of case does better when calomel is used. 
If there is a tendency to vomit, the oil will rareh^ be retained, regard- 
less of how it is given. From y - to -jL- grain of calomel may be given 
at fifteen-minute intervals until one grain is given. While slower 
in its action, it is ultimately of more benefit than the oil which is 
rejected. During the past summer I have used a solution of sul- 
phate of soda (Glauber's salt), as advocated by Dr. L. E. La Fetra, 
of New York, with surprisingly good results. It is well retained, 
even in the vomiting cases, and when given in doses of two drams 
it produces a free watery evacuation without tenesmus. I usually 
prescribe it as follows: 

I^. Sodii sulphatis oj 

Elixiris simplicis § j 

Aquae q. s. ad § iv 

M. ft. solutio. 

Sig. — Two teaspoonfuls every thirty minutes until four doses have 
been taken. 

When the vomiting has subsided, teaspoonful doses of plain water 
or barley-water, granum-water, or rice-water should be used at 
fifteen-minute or half -hour intervals, and both increased as to interval 
and quantity as the case improves. Alcohol in the form of brandy. 



204 GASTRO-ENTERIC DISEASES 

a popular treatment, should seldom be used in these cases, and when 
used, always well diluted, usually in the food. Vomiting babies 
should be given brandy very sparingly or not at all, as it is apt to 
increase the irritability of the stomach. 

Milk Substitutes. — It is well in using milk substitutes, such as 
cereal waters, to use alternately, for the sake of variety, three or 
four different preparations. The child will not so soon tire of the 
milk substitute as when but one is given and more food will be 
taken. It is extremely rare that the substitutes barley, rice, or 
granum will not be taken if used in this way, particularly if made 
more palatable by the addition of salt and sugar. 

The termination of acute intestinal infection is in death, prompt 
recovery, or in the development of ileocolitis. The transition to an 
ileocolitis in some cases is so sudden that its existence from the onset 
is often assumed. That such is not the case is proved by a large 
autopsy experience in hospital and institution work, on cases dying 
in a day or two from toxemia in which no intestinal lesions of conse- 
quence are found. When the diarrhea with loose green mucous 
stools continues with fever, it means that an ileocolitis has developed 
as a result of the action of the bacteria and the absorption of toxins 
by the intestinal mucous membrane. 

Drugs. — Unusual care must be exercised in the use of astringent 
drugs in the cases we are discussing. I refer particularly to cases that 
are mild or moderately severe. It is to be remembered that it is in 
the intestinal contents that the trouble exists, and not in the intesti- 
nal structure, and that the diarrhea is a conservative attempt on the 
part of Nature to protect the intestinal structure. Our first efforts 
therefore should not be directed toward stopping the diarrhea, but to- 
ward assisting in the elimination of the intestinal contents — the 
source of the illness. The indiscriminate use of opium and astringents 
may do irreparable damage in a very short time through a locking 
up of the intestine with its bacteria and their toxins, which may be 
followed by a sudden rise in temperature, convulsions, coma, and 
death. Opium is a most useful drug in diarrhea in children, 
but it must be used with caution. When there is tenesmus 
with frequent large watery stools, it may be given in small doses 
sufficient to control the number and character of the stools with 
a view to preventing an excessive loss of fluids from the body. 
It should never be given when there are only four or five free evacu- 
ations in twenty-four hours, with more or less fever, as in these cases 
this number is required to maintain proper drainage. The opium 
should further be given independently of other medication so that its 
use may be stopped when the excessive number of stools ceases or in 
the event of a rise in temperature after it has been given. It would 
not be desirable, perhaps, to discontinue the bismuth or other drugs 
which may have formed a part of the prescription. In using 



ACUTE GASTRO-ENTERIC INFECTION 205 

opium I prefer the Dover's powder, i to ^ grain at intervals of 
two or three hours, for a child from six to eighteen months of age. 
Bismuth subnitrate in not less than ten-grain doses at two-hour 
intervals has given mos;t satisfactory results. In order to be of 
service it must produce black stools. In other words, if the bismuth 
is not converted into the sulphid in the intestine it apparently is of 
no service ; if it passes through the bowel unchanged, no favorable 
influence will be exerted on the intestinal contents. This occurs 
in a small percentage of cases. In such an event the necessary 
amount of sulphur is supplied by the use of the precipitated sul- 
phur, one grain being added to each dose of the bismuth. A 
convenient and agreeable way of giving the bismuth is the following : 

I^. Bismuthi subnitratis 5 v 

Syrupi rhei aromatici 5 iij 

Aquae q. s. ad o iv 

M. Sig. — One teaspoonful every two hours. 

If sulphur is necessary a one-grain powder may be added to each dose 
of the bismuth mixture at the time of its administration. In the 
same way Dover's powder, if opium is indicated, may be dropped into 
the bismuth mixture. The bismuth is continued in the large doses 
until the child is ready for milk, when the dose is diminished one-half 
and continued until full milk-feeding is permissible or until con- 
stipation demands its discontinuance. In using the bismuth in the 
large doses advised, it is necessary that the chemically pure drug 
oe obtained. If free nitric acid or arsenic is present, as is the case 
in some of the commercial bismuth on the market, vomiting may 
result or symptoms of arsenical poisoning may develop. Irrigation 
of the colon (page 219) may be used when there is a tendency to 
bowel inactivity with high temperature. With loose watery passages 
it is not called for. 

Hypodennoclysis. — The injection of warm normal salt solution 
into the cellular structures of the body is frequently advocated by 
pediatric writers in the very urgent cases in which there is extreme 
prostration and rapid loss in weight due to the persistent watery 
discharges. I have employed this treatment in a great many cases 
and have never demonstrated that it is a measure of any great 
utility. In the cases where the addition of the fluid is needed most, 
it will not be absorbed because of the lowered vitality of the patient. 
Those whose tissues are able to take up the salt solution appear to do 
well without it. 

Diet. — A difficult problem of no little importance is the nutri- 
tion of the patient after the acute symptoms have subsided. When 
the temperature has been normal for two or three days, when the 
character of the stools improves to such a degree that freer feeding 
than carbohydrate decoctions is to be thought of, unusual care is 
necessary in order to avoid a reinfection. 



2o6 gastro-bntkric diseases 

Skimmed Milk. — It must, of course, be our effort to resume 
milk-feeding as early as possible, but in resuming milk the amount 
given must be increased very gradually, giving at first only one- 
quarter to one-half ounce of skimmed milk in every second feeding 
of the cereal gruel. In not a few cases, even these small amounts 
will result in a rise of temperature and a return of the diarrhea. 
There are always bacteria remaining in the intestinal tract after an ill- 
ness of this nature, which, under the influence of such a favorable 
culture-medium as milk take on renewed activity, and the whole ill- 
ness may be repeated, perhaps with greater severity than the original 
one, if the milk- feeding is persisted in. I have repeatedly seen in con- 
sultation infants who were having what was called a relapse. What 
they did have was a reinfection with all the symptoms as severe or 
more severe than those of the first infection, and all because of a lack 
of appreciation of the necessity of great care in resuming milk. To 
avoid mistakes in feeding at this time, as well as early in the disease, 
all directions should be carefully written. • Nurses and mothers who 
think the physicians are over-cautious and pity the hungry child 
are very liable to forget oral instructions and give more milk than is 
ordered. I always tell these people that when an order is disobeyed 
the responsibility is theirs. If the small amount of milk agrees it 
may gradually be increased by the addition of one-half ounce to 
each feeding every two or three days. Rarely, however, will it be 
possible or wise to attempt to give for the remainder of the summer 
as strong a food mixture as was taken before the illness. In milk- 
feeding at this time super-fat must not be used. Either full milk or 
skimmed milk properly diluted is given. If there is a tendency to 
relaxation of the bowels with frequent passages I order skimmed milk 
to be used. Whether the food shall be pasteurized, steriHzed, or raw 
depends upon the conditions referred to under pasteurization and 
sterilization (page 115). Every summer I have infants under my 
care who after an attack of diarrhea cannot take even as small an 
amount of cow's milk as one-half ounce in each feeding. Not a few 
of the marasmic out-patient infants belong to this class. After a 
sharp intestinal infection with inability thereafter to take a nutritious 
diet, a wet-nurse may be secured for the well-to-do, but the wet- 
nurse's milk will not always agree, as I have repeatedly found. 
Children who have been very ill with any of the severe forms of 
acute intestinal diseases of summer have, as a result, a very weak 
fat-capacity, and the wet-nurse's milk, with its 3 or 4 percent of fat in 
some instances, produces sufficient diarrhea to require its discontinu- 
ance. When employing the wet-nurse in such cases it is best never 
to permit the child to have the full allowance of breast -milk at first. 
For a child from three to six months of age, for example, it is wise to 
give him two or three ounces of barley-water or a 5 percent milk-sugar 
water before each nursing, so that he will be satisfied with two or 



ACUTE GASTRO-ENTKRIC INFECTION 207 

three ounces of the breast-milk. When cow's milk cannot be given 
and the nurse's milk does not agree, or where for any reason a wet- 
nurse is not possible, we are called upon to furnish other means of 
nutrition, and this, with our available resources, will not be of a very 
high order for infants under one year of age. The anim.al broths are 
of very little serA^ce. They contain but little nourishment even if 
given in considerable quantity. They produce a decided laxative 
effect on convalescents from diarrhea. Their only use is in giving ' 
small quantities, an ounce or two added to the gruel to make it more 
palatable. 

Strong starchy foods cannot be digested in sufficient amount 
to maintain the nutrition. It is under such conditions that dex- 
trinizing processes (page 125) are of considerable service. The 
starch is thus converted into maltose, which is readily assimilable. 
Here, as in the broth, the relaxing effect of the food on the intestine 
may be felt, frequent bowel evacuations being a possible result. 
The dextrinized gruels, however, are always worthy of trial, and 
they have been of considerable service in many cases as a substitute 
for cow's milk. When breast-milk is impossible, canned condensed 
milk usually answers better than any other means of nutrition. It 
is much more easy of digestion than is fresh cowl's milk, as is well 
known. It is added in small quantities at first to the cereal water 
made from barley, rice, or granum. No. i strength being employed. 
(See formulary, page 129.) One-half dram may be added to every 
second feeding for the first day. The following day this amount 
may be added to every feeding. It usually will be well taken and 
well digested. It is gradually increased until two, three, or four drams 
are added to each feeding. W^here it seems desirable to use more than 
two drams to each feeding, the fresh or unsweetened condensed milk, 
if obtainable, furnishes the increased amount of proteid and fat with- 
out the excessive percentage of sugar. In not a few cases the combina- 
tion of condensed milk and cereal diluent must furnish the nourish- 
ment for the remainder of the heated term. With the advent of 
cooler weather, one ounce of weak cow's milk w4th the cereal diluent 
may be substituted for one of the regular feedings, which later may 
gradually be increased one-half or one ounce at a time until the cow's 
milk comprises one-third of the food mixture. When this point is 
reached an attempt may be made to replace with cowl's milk an- 
other feeding of the condensed milk. In this way by carefully 
watching the case a gradual replacing of the condensed milk 
by fresh cow's-milk feeding may successfully be brought about 
until cow's milk only is given. 

After the first year, similar methods may be followed if neces- 
sary, although at this age cow's milk w411 usually be tolerated 
earlier and other means of feeding than the milk may be brought 
into use. Zwieback, bread crusts, and scraped beef — two or three 



208 GASTRO-ENTKRIC DISEASES 

teaspoonfuls a day — will often be taken without inconvenience 
when milk in sufficient amount for proper nutrition disagrees. 
At this age the gruels also may be made stronger; No. 2 or No. 3 
(see formulary, page 130) will often be well borne. An important 
point to be remembered in feeding convalescents from an acute 
gastro-enteric disorder is that the food must not be forced, and 
that the child must be fed only in accordance with his digestive 
capacity. This can best be determined by watching the temperature 
and the stools. The gruels as substitute feedings, whether alone or 
combined with condensed milk, may be given in quantities equal to 
those which the child was accustomed to take in health, but they 
may be given at more frequent intervals, never, however, oftener 
than every two hours. A child who has been fed at four-hour 
intervals may take the substitute at three-hour intervals. If fed 
at three-hour intervals, he may get the substitute at two or tw^o and 
one-half hour intervals. When constipation follows a sharp attack 
of diarrhea, an enema must be used not oftener than once in twenty- 
four hours. The patient should not be given a laxative unless there 
is fever for several days after the acute symptoms have subsided. 

ACUTE ENTERIC INFECTION 

Acute enteric infection is of two clinical forms anci is distinguished 
from gastro-enteric infection by the absence of vomiting. As with 
gastro-enteric infection, while it may be acute in character, it 
can hardly be considered the primary illness, as it is usually pre- 
ceded by a latent type of intestinal indigestion. The onset of the 
urgent symptoms oftentimes is so sudden and so severe that it is 
regarded as the commencement of the illness. The prostration 
may be extreme, the temperature high — 105° to 106° F. The 
eyes are sunken and the face is drawn and pinched. Convulsions 
and muscular twitchings are often present. In institution-infants 
I have seen death take place in less than twenty-four hours as a 
result of the profound toxemia. The milder forms, characterized 
only by a sharp elevation of temperature and moderate prostration, 
respond to treatment in a day or two. 

Treatment. — As mentioned above, there are two types of infec- 
tion, one with diarrhea and one with marked bowel inactivity. 
In neither is there vomiting. In both types castor oil, in doses 
never less than two drams, is to be given. This is followed by 
discontinuance of the milk, whether the patient is bottle-fed or 
nursed. As a substitute, barley-water, rice-water, or granum- water 
No. I (page 129) maybe given with salt and sugar added for fla- 
voring purposes. An advantage in the treatment of these cases is 
that, there being no vomiting, the food is usually well taken 
throughout the entire illness, as the patient is ordinarily very 
thirstv. With excessive diarrhea the indications for medication are 



ACUTE ENTERIC INFECTION 209 

the same as those given under Acute Gastro-enteric Infection (page 
202). Castor oil or sulphate of soda (page 203) is to be used 
instead of calomel, at the beginning of the illness. 

Intestinal infection with defective bowel action often gives us 
our most difficult cases and requires different treatment. In this 
type, poisons generated in the intestinal contents seem to be of 
such a nature as to cause a partial paralysis of the small intestine, 
and it is often with the greatest difficulty that an evacuation 
can be induced. So difficult is it, in fact, that the possibility of 
an acute peritonitis or an intussusception is thought of by the 
physician. It is very necessary to maintain bowel action and to 
prevent the accumulation of gas, which by its distention of the 
intestine increases the tendency to constipation. Several cases of 
this nature with high temperature, sluggish bowel action, and intense 
prostration are seen by me every year. 

A case in point came under my observation during the past sum- 
mer. A female infant nine months of age had been a most difficult 
feeding case. In July she was taken with sudden high fever (105° 
F.) and convulsions, which w^ere followed by muscle twitchings, 
head rolling, and marked prostration. The temperature was uninflu- 
enced by local means, although there was no diarrhea or vomiting. 
The attending physician, anticipating intestinal infection, gave calo- 
mel in divided doses with frequent bowel irrigations. Foul-smell- 
ing fecal material came away with the irrigation, but the temperature 
and the nervous symptoms persisted; in fact, the condition became 
w^orse. I first saw the child when she had been ill, perhaps ten or 
twelve hours, and directed that one-half ounce of castor oil and a 
high irrigation of normal salt solution at 80° F. be given. As a result 
of the treatment there w^as one small green movement in addition 
to what came away with the irrigation, which was considerable. 
The patient w^as relieved somew^hat and the nervous symptoms 
measurably subsided, though the temperature still ranged between 
104° and 105° F. As a result of the calomel, one and one-half grains 
having been given, and the ounce of oil, a free diarrhea w^as looked for. 
It did not appear, however. I then directed that one-half ounce 
of castor oil be given daily in addition to the irrigations every eight 
hours. This was followed by a sUght improvement in the symptoms, 
but it required five days of the treatment, one-half ounce of oil and 
one grain of calomel being given daily, with abdominal massage, 
before the resulting peristalsis was sufficient to relieve the intestine 
of its contents. After the establishment of free bowel action, the 
child recovered. 

A similar case which resulted fatally was seen in consultation. 

In this case, a girl eight years old, the toxemia was intense. There 

appeared to be almost complete paralysis of the small intestine. 

Only small, very foul evacuations could be induced, in spite of the 

14 



2IO GASTRO-KNTHRIC DISEASES 

most active local and internal measures. The child died from 
toxemia, before free bowel action could be established. 

The management of these cases of the inactive type is partially 
illustrated in the histories above given. Our efforts are to be directed 
toward supporting the patient by the use of stimulation, hypoder- 
mically or by the stomach, and by the use of a non-milk diet, power- 
ful laxatives, and frequent colon flushings. Castor oil will often 
need to be given repeatedly and should be given freely — at least 
one-half ounce every twelve hours — until four or five passages in 
twenty-four hours result. Sulphate of soda (page 203) is given with 
satisfactory results in this type of cases. While the fever, prostration, 
and bowel inactivity persist, it is necessary to continue the irrigations. 
In a few cases, apparently better results were secured by using for the 
irrigations cold water (70° to 80° F.) with the addition of Epsom 
salts, one ounce to the pint. 

Stimulants. — Because of the tendency to convulsions and nervous 
irritability, strychnin should not be given. The tincture of strophan- 
thus answers better than any other heart stimulant. Alcohol should 
be used only under the most urgent conditions of prostration. 

If hypodermic stimulation is called for, a combination of tinc- 
ture of strophanthus and brandy, or digitalin and brandy, answers 
well. For a child six months of age, twerity minims of brandy 
with one drop of tincture of strophanthus, or twenty minims of 
brandy with -^^-^ grain digitalin, may be given and repeated according 
to the requirements of the case— every two hours if necessary. 
After the first year, children may be given as much as y^-^ grain of 
digitalin or two drops of the tincture strophanthus. 

Irrigation of the colon (page 219) is now a measure of inestimable 
value, both for its immediate local effect and also for increasing gen- 
eral peristalsis and thus emptying the small intestine. An increase of 
the peristalsis is sometimes well secured by the following procedure : 
After the colon is washed with a normal salt solution at a temperature 
of 95° F. the tube is introduced as far as possible and eight ounces 
of water at 60° F. is allowed to escape. The tube is immediately 
removed and an attempt made by elevating the buttocks and press- 
ing them together to have the child retain the solution for a few 
moments. 

In using nutrient enemata and in colon flushings for purposes of 
supplying fluids to the circulation we have found that the solution is 
best retained when it is introduced warm — at a temperature of about 
100° F. The cooler the solution, the more quickly is it expelled 
through exciting peristalsis. This fact may be taken advantage 
of in these cases of bowel inactivity. After an enema of cool water 
peristalsis of the small intestine will often result in the passage of 
a considerable quantity of its contents into the colon to be expelled 
later with the water. This I have frequently demonstrated. The 



ACUTE ILEOCOLITIS 211 

action of the cool water will be further assisted by maintaining 
light abdominal massage after the tube is removed. Recovery 
may follow the clearing out of the intestine, or an ileocolitis may 
result, as in gastro-enteric infection. The process of transition 
may require but a surprisingly short time, and if recovery is not 
prompt an ileocolitis will almost certainly be the outcome. 

Upon resuming the milk diet the same precautions relating to 
the use of cow's milk must be observed as referred to under Acute 
Gastro-enteric Infection (page 205). 

LACTIC ACID BACILLUS IN THE TREATMENT OF ACUTE INTES- 
TINAL INFECTIONS 

Prompted by the optimism of Metchnikoff and his followers, 
the treatment of the acute intestinal infections of a severe type was 
carried on at the Babies' Hospital during the summer of 1908 in 
the use of cultures of the lactic acid bacillus which were suppHed by 
the Lederle Laboratory. The duration of the treatment ranged 
from two to thirteen days. The observations were made on eighteen 
children, ranging in age from four to fourteen months. At the sugges- 
tion of Dr. Nathaniel Bowditch Potter, who supplied the material, 
a culture of the bacilli, one-half to one ounce in amount, was injected 
into the descending colon daily. In addition to the above, an irri- 
gation of the colon with eight ounces of a solution containing the 
bacilli was used in twelve cases. Again, in six of these the lacto 
bacilHne tablets were administered by the mouth, one-half tablet 
every two hours. Among these cases eleven died. In tw^o there 
was no improvement after the treatment and other treatment was 
instituted. In one there was very slow improvement and the treat- 
ment exerted no benefit. Four recovered under the treatment. 
Among the six that were fed the lacto-bacilHne tablets, five died and 
one recovered. 

As our results with the lactic acid bacillus were so disastrous, 
giving a much higher mortality than the usual methods of treat- 
ment, its use was discontinued and our usual managment resumed. 
Our results with the feeding of milk which had been subjected to the 
action of the lactic acid bacillus will be found on page 1 20. 

ACUTE ILEOCOLITIS 

A great deal of confusion has been occasioned by attempts at 
a nomenclature of the acute inflammatory diseases of the intestine 
which shall make the clinical aspect of the cases fit the pathologic 
findings. Differentiation, ante mortem, into catarrhal, follicular, 
and ulcerative types is impossible, as has been proved by the care 
and daily observation in institution and hospital work of cases 
that have later come to autopsy. Consider briefly, for illustration, 
the gravest cases, cases which at autopsy show most extensive 



212 GASTRO-ENTERIC DISEASES 

ulceration of the intestine. In many of these there was a low 
temperature, from ioo° F. to 102° F., and the stools never contained 
a particle of blood. In others, in which perhaps considerable blood 
was passed for several days, there will be but a mild congestion 
of the mucous membrane of the large intestine. Others will con- 
tinue for a considerable time, from two to three weeks, with mod- 
erate temperature, and die from exhaustion and show nothing at 
autopsy but an enlargement of the solitary follicles with areas of 
congestion in the lower portion of the small intestine. Recent 
work in the bacteriology of the acute intestinal diseases has added 
nothing to our knowledge as to the treatment of the condition, 
and consequently does not call for discussion here. Acute ileo- 
colitis may be the primary intestinal disease. In this condition 
the temperature is usually considerably elevated at the commence- 
ment of the illness. After an evacuation of two or three undigested 
stools, the passages consist of light-colored mucus, oftentimes streaked 
with blood, or they are of green mucus and streaked with blood. 
The passages are small, frequent, and attended with considerable 
pain and tenesmus. I have repeatedly seen from twenty to thirty 
such passages from one patient in twenty-four hours. Far more 
frequently, however, this condition follows an acute gastro-enteric 
indigestion or an intestinal infection, the dangers of which 
were not appreciated, and the case consequently was improperly 
treated, the lesions produced being due to the bacteria and their 
toxins, which had abundant opportunity to produce pathologic 
changes in the intestinal mucous membrane, the extent of which 
could only be conjectured during life. 

The duration of an ileocolitis is longer than that of any of the 
intestinal disorders previously mentioned. With the establishment 
of the disease it is rare for a case to recover under ten days. It 
oftentimes means an illness of two or three weeks, and sometimes a 
longer period must elapse before the usual diet may be resumed. 
The temperature range is variable — from normal to 104° F. There 
is always emaciation. The degree of prostration is dependent 
upon the amount of toxemia, the extent of the lesion, and the man- 
agement of the case, particularly as relates to supportive measures 
and the nature of the nutrition. 

Treatment. — Milk is to be stopped at once, whether the patient 
is breast-fed or bottle-fed. Barley-water, granum-water, or rice-water 
No. I (see formulary, page 129) constitutes the basis of diet for chil- 
dren under one year of age. Older children may be given the No. 
2 strength. To these carbohydrate foods may be added an ounce 
of chicken or mutton broth, with salt or sugar, to make them more 
palatable. It is well, for variety, to make up two or three cereal 
preparations and alternate their use. In this way the foods will be 
better taken and for longer periods than if but one is prepared. In 



I 



ACUTE ILEOCOLITIS 213 

this form of substitute feeding, an amount similar to what the 
child was accustomed to in health may be given, but the intervals 
may be shorter by one-half hour or one hour. 

Drugs. — In a large experience with acute colitis in institution and 
out-patient work, there has been abundant opportunity to test the 
value of different drugs that have been advocated from time to time 
for the disease. Drugs which have proved of unquestioned value are 
castor oil, calomel, subnitrate of bismuth, and opium. Drugs 
which have an occasional application are sulphur and the prepara- 
tions of tannin. Constitutional measures, supportive in character, 
such as heat and stimulation, are, of course, used when indicated, 
as in any severe exhaustive illness. At the commencement of the 
attack, two drams of castor oil should be given. If this is not retained, 
from one to two grains of calomel should be given in divided doses — 
one-quarter grain every hour. Bismuth subnitrate is best given 
according to the suggestions on page 205. The prescription calls 
for ten-grain doses. If black stools do not follow its administration, 
one grain of precipitated sulphur is added to each dose. To be 
effective the bismuth must be given in large doses. Two or three 
grains at intervals of two or three hours are of no value. In cases 
over one year of age, fifteen to twenty grains are frequently given 
at two-hour intervals. When there is much pain and tenesmus 
with frequent, scanty, mucous stools, opium may be used with 
advantage, with a view of controlling the tenesmus and diminishing 
the frequency of the stools. Paregoric or Dover's powder is usually 
selected for this purpose. Dover's powder is preferred because 
of the absence of a disagreeable taste and the convenience of its 
administration. It may be added to the bismuth at each dose, 
not combined with it in a prescription, for uncombined it may at 
once be discontinued or given in smaller doses with a diminution 
in the number of the stools. 

Careful instructions should be given when prescribing opium.. 
It is to be given for a definite purpose, to prevent straining and the 
frequent passages due to excessive peristalsis. As in acute intes- 
tinal infection, particularly if there is temperature, it is not well 
to attempt to reduce the number of the stools below four or five 
in twenty-four hours, and of course opium is not to be given at all 
unless the stools are very frequent. Not a few cases do admirably 
under the cereal water diet, castor oil, bismuth, and sulphur. The 
amount of opium that will be required in a given case may readily 
be determined by carefully watching the character and frequency 
of the stools. For children under one year of age, the dosage of 
Dover's powder is from i to ^ grain at two-hour intervals, not more 
than seven doses being given in twenty-four hours. From the 
first to the tenth year, the dose ranges from one-half grain to two 
grains. Mothers and nurses are to be instructed that when there 



214 GASTRO-ENTERIC DISEASES 

is a rise in the temperature or when the child becomes drowsy after 
its use the opium is to be discontinued or the dose reduced one-half 
— another advantage of giving it independently. The younger the 
child, the greater caution to be observed in its use. Tannalbin, in 
doses of two grains in infants, and from five to eight grains in older 
children, is sometimes of service when there is a tendency to large 
watery stools or stools containing large quantities of mucus. This 
also may be given at the same time as the bismuth. When heart 
stimulants are necessary, the tincture of strophanthus is usually 
selected. Digitalis is not well borne by the stomach, and for the 
same reason, as well as for its unfavorable effect upon the kidneys, 
alcohol should be given with caution. When used, it should be 
well diluted and given only temporarily during the urgent period 
of acute toxemia. Its prolonged use invariably interferes with the 
stomach function. 

Hot Applications. — Hot stupes or hot compresses to the abdo- 
men are often most grateful to the patient, when there is abdomi- 
nal pain and tenesmus. The hot applications should be changed 
every fifteen or twenty minutes, never being allowed to become cold. 

Colon irrigation should be used at least once in every case of 
colitis, normal salt solution being employed at ioo° to 105° F. 
The solution should always be used warm, as it has a pronounced 
sedative effect in some patients when used in this way. It thus may 
fulfil two purposes. Whether the irrigation is repeated or not must 
depend upon its effect upon the patient. When he strains against 
it and there is no apparent diminution in the number of the stools, 
it should not be repeated. Frequently, however, the intestine 
remains quiet and the number of passages diminishes, after a warm 
irrigation — 105° to 110° F. In such cases it may be repeated twice 
daily. In cases in which there is not an active bowel action, where 
decomposing blood and mucus are removed by the washing, it may 
be used once or twice daily. Only in the rarest instances when 
there are high fever and delayed bowel action should intestinal irri- 
gation be practised oftener than once in twelve hours. This line 
of treatment is oftentimes overdone, as is apt to be the case with 
any useful measure. 

Irrigation should always be used for a definite purpose and 
discontinued when that purpose is accomplished. Every year, at 
the close of the heated term, I see cases of chronic coHtis without 
fever which are being irrigated two or three times daily without 
any indication for the irrigation other than the mucous stools. Irri- 
gations, without question, help to keep up the secretion of mucus, 
for I have repeatedly seen it disappear entirely in a few days without 
other treatment after the discontinuance of the irrigation. When 
irrigation is practiced frequently in those with inactive peristalsis, it 
is possible to produce a general edema. This has been done experi- 
mentallv in well children. 



ACUTK ILEOCOLITIS 215 

Starch and Opium. — The time -honored remedy — the injection of 
starch and opium — may be of service in the cases in which there is 
much tenesmus with the passage of small amounts of blood-streaked 
mucus or when bloody mucus exudes from the rectum. In these cases 
the principal lesions are usually located in the sigmoid and rectum. A 
straight-pipe, hard-rubber syringe answers best for this purpose (Fig. 
18). A starch solution of the strength of one dram of starch to an 
ounce of boiled water is used. For infants under one year of age five 
drops of laudanum may be added to two ounces of the starch solu- 
tion and repeated at intervals of six to eight hours. Older children 
may be given from eight to twelve drops of laudanum with four 
ounces of the starch solution ; this may be repeated in four to six 
hours. 

Improvement in the colitis is indicated by a subsidence of 
the temperature, a change in the character of the stools from 
green or clear mucus with blood and scarcely any odor, to pas- 
sages which gradually take on a fecal odor and show the presence 
of feces mixed with mucus. 

The Influence of Climate. — When it is felt that the case is under 
control, a change of climate is most beneficial. A child who has 
had colitis at the seashore or in town, will invariably have its recovery 
hastened by a removal inland to the mountains or among the hills, 
where an open-air life is to be insisted upon. 

Diet in Convalescence. — With a subsidence of the fever and an 
improvement in the number and character of the stools, the patient's 
troubles are not over. The problem of nutrition is often a diffi- 
cult one. The child has necessarily been on a reduced diet for 
several days, oftentimes for two to three weeks. If better nutri- 
tion than cereal gruels is not soon forthcoming, the patient faces 
the danger of malnutrition and marasmus, which is the outcome in 
not a few of the badly treated cases in which the disease is not 
quickly fatal. The use of milk in some form must sooner or later 
be attempted. 

Children who have had colitis bear fat very badly. The 
younger the child, the more certain is this the case. This has 
been so forcibly impressed upon me that I have discontinued 
attempts at feeding these convalescents even with small quantities 
of whole milk. I have found that they do best on a carbohydrate 
gruel as a basis of diet, to w^hich sugar of milk is added in the pro- 
portion of from one-half to one ounce to the pint, thereby furnishing 
material for heat and energy. To this sugar-cereal combination, 
skimmed milk in small quantities is added, not over one-half ounce, 
and that to only one of the feedings, the first day that milk is given. 
If this causes no inconvenience an increase of one-half ounce is 
made at every second feeding the following day, and an increase 



2l6 GASTRO-KNTERIC DISEASES 

of one-half ounce at every feeding the third day. The total quantity 
of food given at each feeding is to remain the same, an equal quan- 
tity of the cereal diluent being removed to make way for the milk 
increase. Thereafter, if all goes well, an increase of one-half ounce 
is made in each feeding every day, until the child is taking his daily 
feedings of skimmed milk one-half strength. In some cases it may 
be found that the child's capacity will be only two ounces of skimmed 
milk at a feeding with the cereal water diluent. Here he must 
be held, perhaps for a week or two, before milk can safely be advanced. 
Usually the younger the child, the more difhcult will be the resump- 
tion of the milk diet. After the first year the nutrition may be 
assisted by a thick gruel, such as No. 2 (see formulary, page 130), 
zwieback, bread crusts, or rare scraped beef — two or three teaspoon- 
fuls daily. For infants under one year of age who cannot take 
even a weak dilution of skimmed milk, one-half to one dram of 
condensed milk may be given in the cereal water diluent. A com- 
bination of the canned condensed milk and granum No. i (page 
130) will usually be well taken. If there is abdominal distention 
from starch indigestion, the granum may be dextrinized (page 129). 
Barley-water also answers well as a diluent for condensed milk. 
In adding canned condensed milk to the cereal water, sugar is to 
be omitted. The milk may be increased slowly until from one 
to four drams are given at a feeding. Under no considerations, 
however, unless we are forced to it, should this diet be permanent. 
After from two to four weeks, the use of cow's milk should be at- 
tempted, replacing one feeding of the condensed by a small amount 
of cow's milk, one-half to one ounce in the customary diluent. To 
the cow's-milk mixture a small amount of cane-sugar, twenty to 
thirty grains, should be added, as the child has been accustomed 
to the sweet food furnished by the canned condensed milk. Obsti- 
nate constipation sometimes fohows recovery from severe ileo- 
colitis. This is to be managed along the lines laid down for the 
management of constipation (page 178). Following an attack 
of ileocolitis, the patient must never be allowed to pass twenty- 
four hours without an evacuation of the bowels. A standing order 
should be given that an enema should be used w^hen this does not 
occur. 

CHRONIC ILEOCOLITIS 
Cases of chronic ileocolitis coming under my care have invari- 
ably been preceded by acute attacks, those that were unusually 
severe or that were badly managed. These cases represent one of 
the forms of malnutrition, but are of such a nature as to require 
special consideration. The patient is emaciated, the skin is dry 
and rough, the circulation is poor, the extremities are cold, and the 
temperature often subnormal, with an occasional sharp rise. The 
abdomen is always distended with gas. The stools usually are loose, 



CHRONIC ILEOCOLITIS 217 

number three to four daily, and contain mucus in considerable 
amount. The mucus may be absent for two or three days, when there 
will be a rise in temperature to from 102° F. to 105° F., when large 
quantities will be passed with a very foul odor. The nervous s}- mp- 
toms are usually marked. The child is irritable and sleeps poorly. 

In assuming the care of one of these cases it is well to inform 
the parents that a rapid improvement is not to be looked for. 
A case under my care at the present time, aged three and one- 
half years, and which is now making satisfactory progress, weighs 
but twenty-three pounds — two pounds less than when she was 
eighteen months old. During the first six months that I treated 
her, there was very slow improvement, in spite of every advantage 
that care and change of climate could afford. The management con- 
sists in diet, change of climate when possible, and supportive measures. 
It is for the physician to find out in a given case what means of 
nutrition is best. These cases vary considerably in their digestive 
possibilities, with the exception that they all bear fat foods badly. 

Treatment. — Diet. — Chronic colitis is very fatal in young infants 
and but few survive. Practically, the only hope for infants under 
one year of age is breast-milk, which at first must be given in 
small quantities. Sugar-water should be given before the nursing. 
These young infants do not do well on starchy foods unless they 
have been dextrinized (page 125); when predigested, they may have 
too laxative an effect and should be given in small quantities. The 
use of starch, therefore, in these cases, for a considerable time at 
least, is limited. 

For older children, after the first year, skimmed milk, rare scraped 
meat, junket, and coddled white of &gg or raw egg usually answer best. 

In children under one year of age for whom the breast is not 
available, the white of egg may be beaten up and given in skimmed 
milk or in dextrinized gruel. No. 3 (page 129), if it agrees, or in plain 
water with salt added. The whites of two or three eggs may thus 
be given daily with benefit. Zwieback or bread crusts may be given 
in small quantities. These cases readily develop the alcohol habit, 
so that if given at all, its use should not be long continued. The 
feedings are necessarily more frequent than in w^ell children. I 
usually feed them five times a day — at four-hour intervals. 

Enemata. — There should be a standing order for an enema after 
every interval of twenty-four hours if no movement from the bowel 
takes place during that time. Absence of bowel movement in these 
cases almost invariably means fever, prostration, and perhaps convul- 
sions. If there is a tendency to constipation, as there will be in some 
cases, some laxative, such as magnesia or the aromatic fluidextract 
of cascara, should be given daily in sufficient amount to insure at 
least one free evacuation. 

Irrigation of the colon is not to be used as a routine measure. It 



2l8 GASTRO-ENTERIC DISEASES 

is indicated whenever there is a rise in temperature, even though 
the bowels moved but a few hours previously. A laxative, prefer- 
ably castor oil or calomel, is given also. The further treatment calls 
for salt baths, oil inunctions, and the open-air life referred to in the 
section on Malnutrition (page 162). 

MUCOUS COLITIS 

Attention has elsewhere been called to the necessity, in some 
of the diseases of children, of ignoring what appears to be a local 
manifestation of disease, and treating the patient along dietetic 
and hygienic lines. This necessity is in no disease better illustrated 
than in mucous colitis, a disease fortunately rare in children, yet 
seen with sufficient frequency to warrant our attention. The patients 
who have come under my care have invariably been of a pronounced 
neurotic type, usually of neurotic ancestry, and invariably from 
a neurotic environment. 

In children with mucous colitis the appetite is capricious, the 
bowels are usually constipated, the child is chronically irritable, and he 
is apt to complain of ill-defined pains in the abdomen, which are never 
very severe and are not necessarily associated with the taking of 
food. There is usually slight generalized pain on pressure. One of 
my cases under treatment at the present time, a child four years 
of age, — the most pronounced case that I have ever had under my 
care, — has never had the slightest evidence of pain on pressure or 
otherwise. With the dejections, there is usually mucus in consid- 
erable amount, occasionally passed in large masses, at other times 
in long tenacious strings, sometimes referred to as "ropy." There 
may be several consecutive days in which little or no mucus will 
be passed, then large amounts of it will suddenly appear. 

The disease rarely follows an acute inflammatory process in the 
intestine. In the majority of instances the previous history has 
been one of obstinate constipation in a markedly neurotic, underfed 
child, the constipation having existed perhaps during his entire life. 
Almost without exception the treatment has been by the use of colon 
irrigations, using various kinds of astringents, such as solutions of 
tannic acid, nitrate of silver, etc. 

Treatment. — Local Measures. — The method of treatment to which 
these cases most quickly respond is to discard those local measures 
which often act as irritants to the intestinal mucous membrane. 
Usually as a result of previous treatment and because of the 
nature of the disease the constipation is most obstinate. For this 
I use the olive oil injection at bedtime, two to three ounces, the 
tube being introduced eight inches into the bowel (page 185). 
After breakfast on the following morning the child is placed at 
stool, and if no passage occurs in fifteen minutes a glycerin sup- 
pository is inserted. By this means one passage daily is usually 
insured, and this, ordinarily, is all that is required. Should this 



COLON IRRIGATION 219 

fail, from one to two drams of the aromatic fiuidextract of cas- 
cara should be given at bedtime in addition, the medication being 
discontinued as soon as it is demonstrated that an evacuation vrill 
occur without it. Local measures other than those suggested for 
constipation are not to be employed. 

Diet. — Not infrequently these patients have been taking a consid- 
erable amount of milk. This is immediately discontinued. In its 
place malted milk or whey is given as a drink. The further diet 
consists of whole-wheat bread, animal broths, cereals cooked three 
hours, eggs, poultry, red meat, stewed fruit, and fruit-juices. Spinach 
and asparagus are the only vegetables allowed at the beginning 
of the treatment, and these by no means should always be given. 
Purees of peas, beans, and lentils are given freely. The use of 
butter is also encouraged. I endeavor to have the patient take 
three ounces daily. It may be given on bread or on the cereal. 

Drugs. — Strychnin and nux vomica appear to exert a very benefi- 
cial influence on these cases. The combination of nux vomica and 
quinin has been very satisfactory. For a child from five to ten years 
of age the following should be ordered : 

I^. Tincturae nucis vomicae gtt. xc 

Quininae bisulphatis gr. Ix 

M. Div. et ft. capsulae No. xxx. 
Sig. — One capsule after each meal. 

A child suffering from mucous colitis invariably shows malnu- 
trition to a considerable degree. For details as to sleep, rest, exer- 
cise, and baths, all of w^hich are more important than medication, 
the reader is referred to the section on Tardy Malnutrition (page 164). 

COLON IRRIGATION 

Colon irrigation was brought prominently into. use about fifteen 
years ago as a remedy in the intestinal summer disorders of young 
children. While unquestionably its usefulness in this respect has 
been overestimated, and the irrigation overdone, in selected cases 
it is of great service. Because a child has a summer diarrhea, 
a colitis, or any disorder of the intestine, it does not follow that 
irrigation is indicated, or that he will be benefited thereby. A 
child who is having a passage from the bowels every half hour or 
hour is not, according to my observation, a fit subject for irrigation. 
The colon is kept empty by the active peristalsis and the washing 
will remove nothing more than a few shreds of mucus. The cases 
benefited by irrigation are those in which peristalsis is not particu- 
larly active. When a child is running a temperature of 102° F. 
and over, with five or six green mucous passages daily, one or two 
colon irrigations a day will unquestionably be of service in removing 
the offending material from the intestine. 

Every year we see a few cases of intestinal infection, particularly 
those of a very acute type, in which there is high fever, intense 



2 20 



gastro-e:nthric diseases 



prostration, and infrequent bowel action. Occasionally we see a 
case of this sort in which there is no movement whatever without 
assistance. In such cases colon irrigation is of inestimable value, 
and may be used with advantage as often as once in six or eight 
hours. The washing, even if properly conducted, is apt to be strongly 

objected to by the patient 
and should be completed 
as soon as possible. Too 
frequent irrigations, with 
strong medicated solu- 
tions, may keep up the 
mucous discharge indefi- 
nitely. In a few children 
the resistance with strain- 
ing is so marked and so 
continuous that irrigation 
is impossible. These are 
usually children who, on 
account of the excessive 
peristalsis, do not require 
irrigation. 

The irrigation is con- 
ducted as follows: Nor- 
mal salt solution at 95° F. 
is ordinarily used and a 
quart usually suffices. If 
there is a great deal of 
mucus and blood a i per- 
cent tannic acid solution 
is better. The irrigation 
should be continued until 
the solution returns clear. 
The temperature of the 
solution may be varied 
with advantage, depend- 
ing upon the nature of 
the case; thus, in cases 
with subnormal temperature and intense prostration, cases of the 
so-called "algid " type, the solution at 110° F. will act as a decided 
stimulant. It raises the temperature, improves the pulse and the 
general condition of the patient. In cases with high fever — io5°F. 
or 106° F. — a cold solution answers better. I have repeatedly used 
it as low as 70° F. , and have often found that an irrigation with four 
pints of water at 70° F. would reduce a temperature three degrees. 

For irrigation, a soft-rubber catheter. No. 18 American, is best, 
for the reason that its walls are stiff and the tube does not easily 




Fig. 21.— Colon Irrigation. 



INTESTINAL OBSTRUCTION 221 

bend upon itself, as is apt to be the case when an ordinary catheter 
is used. Should this occur, the water may escape an inch or two 
within the rectum, and obviously be of no service. When the 
tube, well lubricated, has been introduced for nine inches, the tip 
will have passed into the descending colon, and further introduc- 
tion will be of no advantage. In order to be sure that it is in 
the colon, gentle palpation over the left side of the abdomen will 
enable one readily to locate it. The tube is attached to an ordinary 
fountain syringe by passing the distal end over the smallest rectal 
tip, which is a part of the outfit of every fountain syringe. The 
bag should be held not over three feet above the child's body. 
When the water is allowed to run, the buttocks should be pressed 
together, for by so doing we hope to flush the entire large intestine. 
If this can be done, the irrigation will be most efficient. 

In this connection I would mention a beneficial effect of irriga- 
tion, of which we hear but little, viz., the absorption of a portion 
of the salt solution by the intestines (page 210). Not a few of the 
intestinal cases have a very limited food capacity. As a result 
of the vomiting and very frequent liquid stools, the bod}^ is thor- 
oughly drained of fluids. In such cases, after the washing is com- 
pleted, I endeavor to have the child retain as much as possible of the 
normal salt solution. As an aid to this, the child should be placed 
on its left side with the buttocks elevated and the tube introduced 
well up into the descending colon. The buttocks should be pressed 
together so as to assist the child in retaining the water after it has 
passed into the bowel. When a half pint or a pint has passed in, 
the tube should quickly be withdrawn and the child kept for half 
an hour in a recumbent position with the buttocks elevated. The 
salt solution will be best retained when it is used warm, at a tempera- 
ture of from 100° to 105° F. 

INTESTINAL OBSTRUCTION 

Agencies impeding or preventing the normal evacuation of the 
bowels may be either congenital — due to a malformation of some 
portion of the intestinal tract — or they may be acquired. Congeni- 
tal malformation may be found in any portion of the tract, but 
it is most frequently seen at or near the outlet or in the region of 
the duodenum. Silverman states that 42 percent of the cases of 
congenital malformation are in the duodenum. When it occurs at 
the outlet, there may be an imperforate anus, or the absence of, 
or atresia of, the lower portion of the rectum. 

The treatment of this deformity is surgical. The most common 
cause of acquired obstruction is intussusception (page 223). Periton- 
itis, both acute and chronic, may cause a cessation of bowel action. 
Tuberculous peritonitis, through the formation of fibrinous bands and 
adhesions, may cause sufficient constriction of the gut to prevent the 
passage of the intestinal contents. In such cases also rehef is best 



222 GASTRO-KNTKRIC DISKASES 

furnished by surgical measures. Acute infective peritonitis (page 
491), producing a complete cessation of peristalsis, acts indirectly as 
a means of preventing the normal passage of the bowel contents. 
The infection is usually secondary. Operative procedures may be 
attempted, but all of my cases have been fatal. Two were operated 
on, as it was feared there might be an intussusception or a volvulus. 
In one case peritonitis followed pneumonia, the infection being 
due to the pneumococcus. 

Strangulated hernia is a condition by no means difhcult of diag- 
nosis and demands prompt surgical relief. 

Illustrative Cases. — Fecal impaction was found in two of my 
cases with intestinal obstruction. Both were seen in consultation. 
There had been prolonged constipation with insufficient evacuations 
owing to neglect on the part of the attendants. The duration of 
the condition it is impossible to state, as the children were permitted 
to go to the toilet alone, and as both were under five years of age, 
but little dependence could be placed upon their testimony. In 
both cases enemata and cathartics had been tried in vain. There 
was vomiting and slightly distended abdomen. There was no fever 
and no marked tenderness on pressure. In my opinion, the vomit- 
ing was due chiefly to the medication, for it ceased when drugs 
were discontinued. Both children responded to massage and in- 
jections of molasses and water. Eight ounces of molasses and 
eight ounces of water were introduced by means of a rectal tube 
at intervals of four hours. One case was relieved after the second 
injection, the other after the fourth. Massage was early brought 
into use. This was given for thirty minutes and repeated after 
an interval of ninety minutes. The interrupted massage was con- 
tinued until an evacuation occurred. 

An unusual case of intestinal obstruction was seen in a wretched, 
premature infant, five months of age, weighing about seven pounds. 
The child had a congenital heart lesion and deformities of the ears. 
It was suddenly taken ill with vomiting and the passage was pale 
mucus streaked with blood. No tumor could be felt, but a diag- 
nosis of intussusception was made and the abdomen opened. At the 
site of the obstruction was a Meckel's diverticulum which had twisted 
the gut so as to prevent the passage of gas or intestinal contents. 

Intra-abdominal tumors, such as sarcoma of the kidney and hydro- 
nephrosis, may cause obstruction through pressure on the intestinCo 

APPENDICITIS 
Appendicitis in children is so essentially a disease requiring sur- 
gical interference, that little need be said of it here. Inflammation 
of the appendix is a more serious condition in the child than in the 
adult and less delay in surgical procedure is permissible. There 
is a much greater tendency toward suppuration than in the adult, 
because of the presence of a lymphoid structure within the appendix. 



INTUSSUSCEPTION 223 

Treatment. ^Until surgical procedure can be brought into use, 
the patient should be kept as quiet as possible in bed. Fluid diet 
in the form of broth and gruel should be given. A saline laxative 
should be used to keep the bowels open. Citrate of magnesia is palat- 
able and is usually well taken by most children. An ice-bag should be 
placed over the appendix and kept constantly applied. If for any 
reason operation is inadvisable or impossible, the broth and gruel 
diet, the ice-bag, and the recumbent position should be continued 
until every indication of pain and rigidity of the rectus has disap- 
peared. If the patient has the good fortune to recover, a suitable 
time should be selected for an interval operation; for a second 
attack is very liable to follow and is always more severe than the first, 
abscess formation being very probable. Further, the second attack 
may occur when the child is otherwise ill, or is away on his vacation 
or at school, where the necessary surgical skill cannot be obtained. 

INTUSSUSCEPTION 

Intussusception is such a distinctly surgical affection that, like 
appendicitis, it requires but little notice here. When there are 
clinical signs of persistent vomiting with bile-stained vomitus; 
when there is marked prostration with low temperature; when 
the stools consist largely of white mucus streaked with blood or 
perhaps with moderate hemorrhage, all characterized by sudden 
and severe onset, whether a tumor is present or not, a surgical 
proposition in a great majority of the cases is before us. Of the 
fifteen cases I have seen, all but one occurred in well-nourished 
nursing babies, in whom there had been no previous illness, other 
than constipation. The youngest nursing baby was two weeks 
old; the oldest, ten months. The older child was two and one- 
half years of age. The high mortality reported by the surgeons — 
from 50 to 80 percent — is due to two factors: the tender age of the 
patients and the delayed operation. 

The cases seen in consultation and those seen in children's hospi- 
tals usually had been treated for something other than intussuscep- 
tion. Sometimes such treatment has been continued for several 
days. By the time these cases reach the hands of the surgeon, there 
may be extensive adhesions, gangrene of the involved portion of the 
intestine, and an exhausted child to deal with. 

Reduction by Water-pressure.— It is my custom in such cases first 
to send for the surgeon and then make one attempt at reduction by 
water-pressure : A well oiled catheter. No. 18 American, or a small rec- 
tal tube is attached to the small hard-rubber tip of a fountain svringe. 
Two quarts of a normal salt solution is placed in the bag, which is 
hung at an elevation of four feet above the child's body. The colon, 
or that part of it below the intussusception, is slowly filled with a 
warm salt solution. A small wet towel is tightly wrapped around 



224 gastro-kntkric diseases 

the catheter and fairly strong pressure made at the anus by an 
assistant in order to prevent the escape of the fluid. With the 
child on his back with both hands free, the buttocks are elevated 
on a pillow or bed-pan at a plane ten inches above the shoulders. 
In the cases in which the tumor is palpable, an attempt is made, 
by gentle abdominal manipulation, to reduce the intussusception. 
This in two cases I have thus succeeded in doing. 

Illustrative Case. — A child two and one-half years of age was 
brought to my office at midnight with a history of a severe attack of 
colic about 9 o'clock, which was followed by severe attacks of vomiting 
and two stools of mucus and blood. Gentle manipulation of the abdo- 
men showed a large sausage-shaped tumor, about five inches long, in 
the left hypochondrium, which I diagnosed as an intussusception. 
The tumor could not be felt by rectal examination. Water-pressure, 
as described above, with abdominal manipulation, reduced the intus- 
susception in a few minutes. The other case was in a baby nine 
months of age. I saw the child in consultation after the intus- 
susception had existed for six days. The child was unconscious 
and in profound collapse. He was pulseless, but the heart-sounds 
could be faintly distinguished by the aid of the stethoscope. The 
rectal temperature was 96° F. The abdomen was greatly distended. 
The child had been treated for cholera infantum, although, for five 
days, nothing but white mucus tinged with blood had been passed. 
Palpation revealed a sausage-shaped tumor extending along the 
entire left side of the abdomen, which in spite of the abdominal 
distention could easily be made out by firm pressure. The child 
was unconscious, so that there was no resistance to the examination. 
By rectal examination the projection of the involuted gut, which 
resembled the cervix uteri, could readily be distinguished. The 
condition of the child precluded all chance of surgical relief, and 
I hesitated to use water-pressure, fearing that the gut might 
be gangrenous and a rupture result, or that there might be 
adhesions sufficient to prevent reduction and that the child might 
die during the manipulations. I explained the situation to the 
parents, who, after considerable urging, consented to a trial being 
made. The patient was accordingly given y^ grain of strychnin, 
one drop of tincture of strophanthus, and thirty drops of brandy 
hypodermatically. The water-pressure was applied in the usual 
way, and it was with the greatest surprise and with supreme satis- 
faction that I felt the tumor slowly give way, to be followed by 
an expulsion of gas and a quantity of very fetid fecal matter. A 
hot colon flushing at 110° F. with a normal salt solution was given 
a few minutes later. This was all retained, and six hours later 
twelve ounces more were given. Hot-water bottles and bags were 
placed about the child. He had sufficiently revived in an hour after 
the first colon flushing to be able to swallow diluted brandy and egg- 
water, both of which were freely given. A rapid recovery followed. 



FISSURE OF THE ANUS 225 

This case, to me, was interesting in many ways, particularly as it 
emphasized what we sometimes see in work among children when 
victory is snatched from the jaws of evident defeat — that we should 
never cease our efforts so long as life lasts. It is my practice to 
make but one attempt at reduction by water-pressure. When 
this does not succeed after a five-minute trial, immediate operation 
gives the patient his only chance of recovery. 

INFLAMMATION OF THE ANUS 
An acute painful inflammation of the anus and of the skin sur- 
rounding it is frequently seen in children after a diarrhea of some 
days' duration. It is also seen in weakly, delicate children without 
any marked intestinal disturbance. The inflammation produces 
considerable distress during the passage of a stool and is conducive 
to constipation, because the child soon dreads to have a bowel 
movement and tries to avoid it. The child's nutrition and manage- 
ment in general must first be carefully looked after, as suggested 
elsewhere (page 177). For the local trouble, the free use of hot 
water after each defecation is necessary. This is to be followed 
by a generous application of an ointment made as follows: 

I^. Ichthyoli 5 j 

Unguenti aquae rosae § j 

Instructions are given that the parts are to be kept covered with 
the ointment, by applying it on a piece of old linen which should 
be changed every three hours. This treatment is usually followed 
by prompt relief. 

FISSURE OF THE ANUS 

Anal fissure is a condition usually seen in quite young children. 
I have seen comparatively few cases in those over two years of 
age. Rough manipulation may be a cause, which may result from 
the unskilled use of the syringe or rectal tube. I have seen one 
such case. With very few^ exceptions, however, the fissure is due 
to the stretching of the parts by the passage of large fecal masses, 
causing minute lacerations of the mucous membrane within the 
anal ring. A good light and gentle separation of the buttocks 
will usually bring the laceration into view. There are few more 
painful affections. The vigorous crying preceding and during the 
defecations helps the mother to locate the source of the trouble. 
Occasionally the fecal mass will be streaked with blood. Caused, 
as it is, by constipation, the painful nature of the condition tends 
to delayed bowel action, as the child soon learns to dread a movement, 
and postpones it until medication or some manipulative means are 
employed to induce it. 

A few months ago a little girl, twenty months old, was brought 
to me because she cried and objected to being placed in position 
15 



226 GASTRO-KNTBRIC DISEASES 

for a bowel evacuation, and cried much harder during the evacua- 
tion. The day preceding the visit to my office the mother feared 
that the child would have a convulsion, so great was her distress. 
Examination of the rectum showed two rather small fissures extend- 
ing through the anal mucous membrane. 

Treatment. — Diet. — For a prompt repair of the fissures, it is nec- 
essary to render the stools soft. This, in the bottle-fed, is often 
easily accomplished by the addition of one of the malted foods, 
either Mellin's food or malted milk — one or two teaspoonfuls being 
added to the regular milk mixture — or one feeding of malted milk 
each day may be substituted for one of the regular feedings. It 
may be used in the strength of four to six teaspoonfuls in eight 
ounces of water. 

Drugs. — If drugs are necessary or are preferred, one or two tea- 
spoonfuls daily of the milk of magnesia given in the milk food will 
answer well. A teaspoonful of sweet oil after two or more feedings 
will usually have the desired softening effect upon the stool. 

Local Measures. — Proper regulation of the bowel function, while 
absolutely necessary for a cure of the laceration, is not of itself suf- 
ficient to effect permanent rehef. The parts must be thoroughly 
washed with warm water and castile soap after each defecation. 
After the washing, and at three-hour intervals during the day, 25 per- 
cent of ichthyol in zinc ointment should be applied with a clean index- 
finger, which is introduced well up into the anal aperture. If the 
fissure is a deep one, it will be well to begin the treatment by cocainiz- 
ing the parts, using a 3 percent solution of cocain, and then cauterize 
with a 50 percent solution of nitrate of silver, which is applied on a 
cotton-tipped probe. Twelve hours later the ichthyol ointment may 
be used as in the milder cases. I have yet to see a case which did 
not respond to the above treatment if it was faithfully carried out. 

THE INTESTINAL PARASITES 

The most common of the intestinal parasites found in children 
are of three types: Ascaris lumbricoides, or round-worm; the Ox- 
yuris vermicularis, or thread-worm; the Taenia, or tape-worm. 

Round -worms. — The round- worms, if in considerable number, 
may produce colic or constipation, the latter oftentimes alternating' 
with diarrhea and with nervous disturbance, sometimes of an 
urgent character. In the great majority of my cases, however, 
no symptoms whatever were present, and the fact that the child 
had parasites in the intestine was first learned when one was found 
to have been passed by the rectum. In one of my cases, in a child 
three years of age, there had been repeated convulsions. The 
mother stated that the child had passed a couple of round-worms 
the day before. I gave one-half ounce of castor oil, which was 
followed, in one hour, by two grains of santonin. Forty-three 
large round-worms were passed during the next twenty-four hours. 



THE INTESTINAL PARASITES 227 

This is the largest number that I have known to come from one 
child. The round-worm is rare in New York city children. I 
have seen but five cases. In children who live in the country it 
is of fairly common occurrence. 

My treatment is as follows: At bedtime I give from two to 
four teaspoonfuls of castor oil. Early the following morning, about 
two hours before breakfast, santonin is given. For children imder 
two years of age, I give one. grain; for those from two to four 
years of age, one and one-half grains; after the fourth year, two 
grains may be given. It is prescribed in a powder with an equal 
quantity of sugar of milk, or in capsule. If the passage of worms 
follows its use, the treatment is repeated in three days, and again in 
a week, if worms are passed after the second treatment. 

Thread-worms. — Thread-worms or pin-worms are more frequently 
seen in city children than are either round-worms or tape-worms. 
They produce an irritation and itching about, and a pricking sen- 
sation within, the anus which is bitterly complained of after the 
child is in bed for the night, the parasites being particularly active 
at this time. If there is any doubt as to their presence, the patient 
should receive a full dose of castor oil — at least two teaspoonfuls. 
The discharges should be kept for inspection. If the parasites 
are present, they will be seen in the form of pieces resembling white 
thread, from one-fourth to one-eighth inch in length. They will 
usually be found embedded in a considerable quantity of mucus. 

Treatment. — Drugs. — Santonin, recommended by some writers as 
of service in these cases, has been without the slightest value in my 
hands. In fact, the use of drugs of any kind seems to be of very 
little service. After the third year, turpentine in one-drop doses 
after meals is probably the most valuable internal medication. It 
may be given in emulsion or dropped upon sugar. 

Rectal Injections. — Local treatment with the infusions of garlic or 
quassia must be our principal reliance in the management of these 
oftentimes obstinate cases. In patients in whom the worms have 
existed for a considerable time, the resulting irritation will cause a 
profuse secretion of mucus in the descending colon and sigmoid. 
This mucus must be washed out before any direct treatment can 
be brought to play upon the parasite. The colon is first irrigated 
with a solution of one tablespoonful of borax to a pint of water. 
For this purpose a No. 18 American catheter should be used, as in 
colon flushings. The tube should be introduced for at least ten 
inches. No attempt is made to have the solution retained. The 
child is encouraged to bear down and expel the water alongside of the 
tube. After the washing is completed, eight ounces of the infusion 
of quassia is passed into the colon. To facilitate its retention the 
tube is quickly withdrawn, and the child placed on his left side 
with the buttocks elevated on a pillow. This position, or at least 
the recumbent position, should be maintained for one-half hour 



228 GASTRO-ENTERIC DISEASES 

after the injection is given. A solution of the bichlorid of mercury 
I : 10,000 may be used in the same way. For ordinary family use, 
however, I consider either the garHc or the quassia much safer and 
equally effective. Garlic is particularly effective, but its very dis- 
agreeable odor makes its use objectionable in many households, and 
therefore I advise it only when other means fail. After the worms 
and the evidence of their presence disappear, the treatment should 
be continued for a time on alternate days, and then twice a week, 
gradually reducing the frequency of the irrigations until they are 
no longer required. Few cases recover in less than four weeks, 
and in many it will be necessary to continue the treatment for 
months. I have never seen a case, however, which did not event- 
ually respond to persistent treatment. 

The Tape-worm. — The tape-worm may produce symptoms of 
disturbed intestinal digestion, such as cohcky pain and diarrhea. 
Usually, however, the first warning that the child is affected will 
be the passage of segments of the worm. 

A worm fourteen feet in length was passed, after treatment, 
by a little girl four years old. There had never been a symptom 
of its presence other than the passage of several of the segments. 

The treatment is as follows: At bedtime give one-half ounce 
of castor oil. Early the next morning, two hours before breakfast, 
give one-half dram of the oleoresin of male-fern (aspidium) in emul- 
sion or in capsule. During the day a light fluid diet only is to be 
given, such as broth, gruels, and fruit- juices. One treatment with a 
good preparation of the male-fern will usually bring away the worm 
entire. The head should be carefully searched for with a magni- 
fying glass. If it is not found, the treatment should be repeated 
after an interval of twenty-four hours. 

PROLAPSE OF THE ANUS AND RECTUM 
In anal prolapse there is an eversion of the mucous membrane, 
a condition often present in constipation and sometimes seen in 
diarrheal conditions of the dysenteric type, in which there is apt 
to be considerable tenesmus and straining. If the case is neglected, 
the prolapse occurring repeatedly for many days in succession in 
cases of constipation, or several times a day in the acute intestinal 
cases, the sphincter gradually becomes weakened, the prolapse 
more pronounced, and soon a considerable portion of the involuted 
rectum appears with each defecation. 

Cases of simple eversion are usually relieved by controlling the 
diarrhea, or, when due to constipation, by supporting the perineum 
during defecation. This support is best furnished by wrapping 
a considerable quantity of absorbent cotton around the index- finger, 
which rests against and supports the perineum. The child should lie 
on its back during defecation. The troublesome cases are those due 
to constipation in "runabout" children, where the prolapse has been 



PROIvAPSK OF THE ANUS AND RECTUM 229 

repeated every day for several months. Such children usually show 
evidence of illness other than the local conditions and the consti- 
pation. They are usually underfed and poorly nourished. Many 
are rachitic or show the ear-marks of a previous rachitic state. 

Operation Contraindicated. — The reduction of the prolapse can 
usually be readily effected by pressure on the protruding mass with ab- 
sorbent cotton which has been dipped in warm sterilized olive oil. 
The only means of permanently curing prolapse of the rectum and 
anus, is effectively and at once to prevent the recurrence. Operation 
by removing sections of the mucous membrane, thus narrowing the 
rectal outlet, the use of the actual cautery or of nitrate of silver, is 
unnecessary according to my observation. Oftentimes such opera- 
tions are productive of much harm. They are unnecessary, because 
the case will get well with much simpler means ; and harmful because 
of the pain and the days of discomfort which may follow such pro- 
cedures, to say nothing of the dangers of infection and the possibil- 
ities of resulting stricture and deformities of the parts. 

Treatment. — Hygienic. — In undertaking a case of habitual pro- 
lapse of the rectum it is necessary that the child be put in the most 
favorable physical condition. As these children are usually consti- 
pated, the diet advised for the constipated (page 182) should be 
used. If thread- worms are present as a cause, the treatment should 
be directed toward their removal. If the child is anemic or rachitic, 
means must be employed to bring the physical condition up to the 
highest possible standard. 

Postural. — When we have properly prepared the patient, by 
thus carefully attending to his general condition, we are in a posi- 
tion to relieve the prolapse. We begin as follows: At bedtime 
introduce into the colon four ounces of warm sweet oil (page 185). 
This will rarely cause an evacuation. In case this should happen, 
only one or two ounces should be used. The following morning, 
after the first meal, the child is placed in a recumbent position 
on a bed-pan with the buttocks elevated to a plane at least four 
inches higher than the child's shoulders. In order to establish the 
habit of a daily evacuation at a proper time, a glycerin suppository, 
infant size, is inserted. If an evacuation does not take place 
within a few minutes, eight ounces of soap- water should be intro- 
duced. After a few days of the suggestion afforded by the prepara- 
tion, the position of the patient, together with his natural efforts 
toward a movement of the bowels, will render artificial stimulation 
unnecessary. The advantages of postural treatment are obvious. 
By lessening the abdominal pressure, which is much greater when 
the child is in the upright position, much less force is exerted on 
the weakened structures, and the patient is in a position in which 
the attendant, by suitable perineal support, by pressing the but- 
tocks together, may better prevent the prolapse. If the case is 
a severe one, the recumbent position for each daily evacuation must 



230 GASTRO-ENTBRIC DISE:ASKS 

be continued for six weeks or longer before the defecation is allowed to 
occur with the child in the sitting posture. If later the prolapse is re- 
peated, four weeks more of the postural treatment must be carried out. 

Supplementary. — After the child is apparently cured, the bowel 
function must be carefully watched for months ; twenty-four hours 
should never pass without a movement. If a laxative is necessary, 
as, in a few cases, it will be, two or three teaspoonfuls daily of the milk 
of magnesia given in the child's milk affords a satisfactory laxative, 
as it produces a soft stool and does not have a pronounced effect 
upon intestinal peristalsis. Two or three teaspoonfuls of olive oil 
given after each meal will often produce the desired laxative result. 
At the same time it is no small addition to the child's nourishment. 

The child at first may not take kindly to the postural treatment ; 
but after a reasonable amount of coaxing and bribing, he soon 
becomes accustomed to it. I have never had any trouble in hav- 
ing the directions carried out, because of the objections of the child. 

ISCHIORECTAL ABSCESS 

An abscess of this type is occasionally seen in infant asylums, 
babies' hospitals, and in out-patient work. It is usually found in 
ill-conditioned children. Such an abscess is generally the result of 
an infection of the lymph-glands in the neighborhood of the rectum. 
As a rule, the abscess is not deeply situated and its cure is easy. 

All that is required is a free incision, a daily washing out of 
the abscess cavity with a 3 percent solution of hydrogen per- 
oxid and packing with sterilized gauze moistened with a satu- 
rated solution of boric acid. A layer of gauze, covered with oiled 
silk, should cover the dressing to protect the wound from further 
infection from the fecal discharges. In case the granulations are 
sluggish, as they may be in marasmic infants, the gauze used for 
the packing may be saturated with the balsam of Peru. 

HEMORRHOIDS 

While a comparatively rare condition in children, hemorrhoids 
are occasionally seen. Constipation and neglect of cleanliness 
appear to have been the cause in most of my cases. The treat- 
ment is to relieve the constipation and carefully cleanse the anus 
with hot water and soap after each movement of the bowels, after 
which an ointment composed of the following ingredients is applied : 

I^. Acidi tannici gr. x 

Pulveris camphorse gr- "v 

Ichthyoli 5 iss 

Unguenti zinci oxidi q. s. ad o j 

The ointment, in addition to its use after an evacuation of the bowels, 
should be generously applied to the anus, night and morning, after 
washing. 



RECTAL POLYPUS. INCONTINENCE OF FECES 23 1 

RECTAL POLYPUS 

According to my observation, rectal polypus is a rare condition. 
My cases have been three in number and in children between the 
ages of five and seven. In all these cases the polypus was discovered 
by the mother after the child's evacuation of the bowels. It may 
easily be recognized as an oval, deeply congested tumor protruding 
from the anal orifice. 

In these children there had been slight hemorrhage from time 
to time with the evacuations, the feces being streaked with blood. 
The polypi, in these cases, were easy of diagnosis, as they were 
situated low down on the rectal wall, each with a rather narrow 
pedicle. They were readily ligated and removed. 

Repeated bleeding from the rectum in apparent health should 
always suggest the possibility of a poh^poid growth. Hemorrhoids 
also are very rare in young children. Pain and tenesmus are early 
signs of fissure, so that bleeding from such a source may readily 
be accounted for. 

INCONTINENCE OF FECES 

Incontinence of feces is a normal condition during infancy, control 
being established without training during the second year or earlier. 
In well-trained infants I have seen the bowel function under perfect 
control at the third month. This is unusual, however. Still, with a very 
little teaching it may be accomplished at the sixth month. Incontin- 
ence of feces in older children occurs during acute inflammatory condi- 
tions, particularly when the colon is the seat of the lesion. It may 
also be present in asthenic states, as in grave pneumonia, in typhoid 
fever, and in severer types of the exanthemata, and it may occur 
accidentally as the result of a fright, shock, or of severe straining. 

Incontinence of feces, as a condition independent of the age 
element and illness, is of exceedingly unusual occurrence. I have 
seen but two cases — both boys, one four and the other seven years 
of age. In both, the condition had persisted for months. The 
desire for an evacuation in these cases came with great urgency 
and was uncontrollable. There was no diarrhea or evidence of 
any intestinal lesion. One was a dispensary patient, the other 
was seen in private. Both were wretchedly nourished children, 
both had been badly managed and badly fed. Incontinence rarely 
occurred at night. During the day, however, it sometimes took place 
two and three times. The patients were on a general mixed diet. 

The treatment was the removal of green vegetables and fruit from 
the diet, allowing only a small amount of starches, such as bread, 
potato, and cereals; eggs, meat, fish, skimmed milk, junket, custard, 
etc. , were given freely. ^ledically they were given fifteen drops of the 
tincture of the muriate of iron in glycerin and water every four hours, 
with one grain of Dover's powder and twenty grains of subnitrate of 
bismuth (Squibb) three times daily. Both cases recovered com- 
pletely, one in three weeks, the other in five. 



THE MOUTH, THROAT, AND NOSE 

STOMATITIS 

The term stomatitis is applied to an inflammation of the mucous 
membrane of the mouth. Three types are usually described by 
pediatric authors — the catarrhal, the aphthous, and the ulcerative. 
This division is perhaps more the result of the habit of copying 
from former writers than from clinical observation. Among sev- 
eral thousand out-patient, institution, and hospital patients, it 
has been my privilege to treat many cases of stomatitis. 

There are many cases of catarrhal stomatitis which under treat- 
ment go no further; other cases, with or without treatment, go 
on to the development of aphthae, or to an ulcerative condition, 
or both conditions may be combined. Many cases, when they 
appear for treatment, have the so-called aphthous spots already 
developed, but the condition described as "catarrhal stomatitis" 
is present also. Other cases when they come to us show marked 
ulceration, but never without catarrhal symptoms. 

The first symptom of a stomatitis is a superficial catarrhal inflam- 
mation of the mucous membrane of the mouth. There is a redness 
and injection of the gums. If "aphthae" develop, small grayish 
plaques appear on the mucous surface of any portion of the buccal 
cavity. In mild cases there may be but three or four areas. In 
a case of moderate severity the mucous membrane of the gums, 
the hard and soft palate, and the inner side of the cheeks will be 
studded with ulcerated grayish-white areas, in size from a pinhead 
to a split pea. Occasionally the areas coalesce, forming larger 
plaques of a serpiginous type. 

Ulceration ordinarily does not appear until after the catarrhal con- 
dition has been present for at least three or four days. It will first be 
noticed as a faint yellow line at the margin of the gum where it joins 
the teeth. This is the commencement of what Virchow describes as 
"necrobiosis." Ulceration never occurs unless teeth are present. I 
have never known a case to go on to ulceration in a baby fed entirely 
at the breast. Whether the case remains simply catarrhal, or whether 
aphthae or ulceration or both result, certain symptoms are common to 
all. There is a marked increase in the flow of saliva, which, in some 
cases, may be said to stream from the mouth, running down over 
the chin and soiling the clothes. On account of its acid properties 
it causes an irritation of the skin, producing an eczema. The mouth 
is hot and painful. Fever is present in a slight degree, both when 

232 



STOMATITIS 233 

the condition is simply catarrhal and when aphthae are present. 
There is but little prostration and the child appears but slightly 
indisposed. In cases which go on to ulceration, the fever may be 
very high. I have frequently seen it at 104° F. or over. In one 
case it reached 107° F. No cause except the ulcerative stomatitis 
could be found for the fever. Under properly directed treatment, 
the child recovered in a few days. 

On account of the pain occasioned by drawing on the nipple, 
nutrition may be considerably interfered with in these cases. The 
child takes the breast or bottle greedily, draws a few times, stops 
and begins to cry. If urged to try again, the process is repeated. 
The pain appears to be particularly severe when aphthae are present. 
The advent of ulceration will be indicated by a change in the breath, 
which becomes disgustingly foul. The gums are thick, spongy, 
and bleed easily, and in some cases overlap the teeth very early 
in the ulcerative stage. If a case has been neglected or improperly 
treated, which was the history of not a few of my dispensary 
patients, the ulceration was often so extensive that the teeth be- 
came loose as a result of the destruction of the gums, and their 
removal was necessary. Strong, vigorous children are as suscep- 
tible to the disease as are the rachitic, the badly fed, or the generally 
delicate. 

The cause of the disease is unquestionably an infection, and 
there is no doubt that it is contagious. As to the nature of the 
infection, positively nothing is known. The combined action of 
several varieties of microorganisms is the most plausible explanation. 
I have known it to go through an entire family of several children. 
Authors are prone to attribute the trouble primarily to mechanical 
irritation, such as careless manipulation during the mouth toilet; 
but the majority of my cases when they applied for treatment had 
never been accustomed to mouth toilets of any kind. The giving 
of overheated food is supposed by some to be a causative agent. 
If this were the case, 75 percent of the infants among the poorer 
classes would never be free from the disease. The food of bottle- 
fed children unless carefully watched is almost invariably given 
too hot. The disease, however, is not limited to dispensary patients. 
I have seen many cases among the well-to-do. Where gross un- 
cleanliness is the family habit, the number of cases of stomatitis 
will, for obvious reasons, be greater; there are more bacteria to 
carry infection. Children whose mouths are carefully cleaned after 
each feeding, do not develop stomatitis. To teach that a child's 
mouth should not be washed because an indifferent doctor may 
fail to instruct the mother or nurse as to how it should be done is 
rank heresy. When errors of the mother or nurse occur in per- 
forming the various offices for the child, it is my observation that, 
nine times out of ten, it is due to the lack of teaching by the careless 



234 THE MOUTH, THROAT, AND NOSE 

physician. The mouth may be very effectually cleansed without 
injuring the mucous membrane in the slightest degree. 

Treatment. — Mouth-washing. — When the stomatitis is catarrhal 
or aphthous, preventive treatment — the washing of the mouth after 
each feeding with a saturated solution of boric acid in boiled water 
— is also curative. A baby's mouth should be washed as follows: 
The child is placed on its side or on its stomach, the index-finger 
of the mother or nurse being thoroughly wrapped in absorbent 
cotton. The finger is then dipped into the solution, and without 
expressing the fluid it is placed in the child's mouth. By gentle 
pressure upon the gums and cheeks a sufficient amount of the fluid 
will be expressed to run out of the mouth and effectually cleanse 
it. The washing is assisted by the opposition offered by the child 
to the manipulation of the tongue, cheeks, and jaws. 

Drugs. — Internal medication is of no value so far as concerns the 
stomatitis, except indirectly. If there is a disordered digestive tract, 
it should receive attention by diet and saline laxatives. Calomel 
should not be given. Whether the condition was catarrhal or 
aphthous, I have never found it necessary to use other means than 
the free mouth-washing. Astringents and caustics have never 
been necessary. The cases usually recover in from four to seven 
days, under strict attention to cleanliness as regards the feeding 
apparatus in the bottle-fed, or the mother's nipple in the nursling, 
together with the free use of the boric acid solution as a mouth-wash. 

Feeding. — ^The food problem is oftentimes a difficult one to deal 
with, particularly in nurslings, on account of the pain caused by draw- 
ing on the nipple, the child refusing absolutely to nurse. In some 
cases it may be necessary to draw the milk with a breast-pump, 
and for a day or two feed the baby with a spoon. In the bottle- 
fed, spoon-feeding may also be resorted to. The child will take 
the nourishment much better if it is given cool. Small pieces of 
ice and teaspoonful doses of cold water are taken eagerly. 

Treatment after Ulceration. — With the development of ulcera- 
tion a change in the management is necessary, both as regards a 
mouth- wash and the necessity for internal medication. Among the 
local measures hydrogen peroxid as a mouth- wash, one part of a 3 
percent solution in two parts of water, used after each feeding, has 
given the best results. Such means, however, are rarely necessary 
if the case is seen early. I never employ other than the usual 
means of cleanliness — the boric acid solution — except in cases that 
show a considerable destruction of tissue. 

Chlorate of Potash. — In the internal administration of chlorate of 
potash we have what is practically a specific in this disease. Its ad- 
ministration should be commenced as soon as the condition is recog- 
nized. I usually prescribe it in the syrup of raspberry, using one part 
of the syrup to two parts of water. For a child under eighteen months 



SPRUE; thrush; mycotic stomatitis 235 

of age I order two grains at intervals of two or three hours, not 
more than ten grains in twenty-four hours. For a child from eigh- 
teen months to three years of age, two or three grains at the same 
intervals, not more than fifteen grains in twenty-four hours. With 
the above dosage it will be necessary, in the average case, to con- 
tinue the drug from three to five days. A^ery often, after the 
improvement is well marked, I reduce the dose one-half and con- 
tinue it for three or four days longer. 

]\Iuch has been written as to the danger of the internal use of 
chlorate of potash in children, particularly in relation to its effects 
upon the kidneys. If the use of the drug in suitable doses were 
of special danger in this respect, the free use of the chlorate of potash 
and iron mixture, so extensively prescribed in diphtheria in the 
pre-antitoxin period, would have been universally condemned. 
I have never seen any unpleasant effects from its use when given 
in doses from ten to twenty grains daily, and I have used it in 
many hundreds of cases of acute inflammatory conditions of the 
throat and mouth. 

SPRUE; THRUSH; MYCOTIC STOMATITIS 

Thrush consists of a parasitic growth which appears on the 
mucous membrane of the mouth in young infants. Plant, in his 
classification of diseases of the mouth, calls it a fungous growth, 
monilia Candida. The disease makes its appearance in the form 
of small white masses about the size of a pinhead. The tongue 
and the inner side of the cheeks are favorite sites for the growth, 
although in severe cases the entire buccal cavity may be studded 
with it, causing it to look as though finety curdled milk had been 
scattered over the surface. The growth is firmly adherent, and if 
removed forcibly, slight bleeding results. It is invariably associated 
with uncleanliness, and occurs, as a rule, in weakly and marasmic 
nurslings and in the bottle-fed, more frequently in the latter. It 
is rarely seen after the sixth month. 

In an infant with sprue, there is evidence of much pain and dis- 
comfort while nursing or while feeding from a bottle. The disease 
is not contagious. The average case may easily be cured in a week, 
if the directions for the treatment are carefully carried out. Active 
gastro-enteric disturbances, such as vomiting and diarrhea, may be 
associated with sprue, but it is not the rule. Time and again I 
have seen cases of sprue in which there were absolutely no other 
signs of the disease aside from the characteristic mouth lesions 
and the refusal of food. 

If the means of prophylaxis, which will be suggested, are used 
as the daih^ routine, the disease will never appear. 

Treatment. — If breast-fed, the mother's nipples must be washed 
with a saturated solution of boric acid and moistened with alcohol. 



236 THE MOUTH, THROAT, AND NOSE 

diluted one-half, which is allowed to evaporate before each nursing. 
If bottle-fed, the nipple and bottle should be boiled after each nursing, 
the nipples turned inside out and scrubbed with borax water — one 
ounce of borax to a pint of water. Whether breast-fed or bottle- 
fed, the mouth should be washed with a saturated solution of boric 
acid after each nursing. For this purpose a generous amount of 
absorbent cotton is loosely wrapped around the clean index-finger 
of the mother or nurse. This is placed in the cold solution, and 
without pressing out the water the finger is introduced into the 
child's mouth, and, in cases of sprue, brought gently in contact 
with the diseased parts, first with one side and then with the other, 
being pressed upon the tongue and under the tongue. It is well 
to have the child rest on its side or stomach so that the fluid which 
is pressed out by the manipulation of the cotton against the cheeks 
and jaws can readily escape from the mouth. The washing, which 
really amounts to an irrigation, can be done in a few seconds, with- 
out the slightest danger of abrading the epithelium. In obstinate 
cases, the parts may be penciled once a day with a i percent solution 
of formalin, in addition to the other treatment. 

Internal medication is of no value in sprue except in correcting 
any intestinal derangement that may exist, with a view to improv- 
ing the general condition. If the bottle or breast is refused, spoon- 
feeding for a few days may be necessary, and will hasten a cure. 
If the child is nursed, the mother's milk maybe drawn with a breast- 
pump (see page 79) or pressed out with the fingers and fed to 
the child. The domestic remedy, honey and borax, should not be 
used in any of the inflammatory diseases of the mouth in children. 

CANCRUM ORIS; NOMA 
This disease is unquestionably the work of a specific microbe, 
the nature of which is unknown. The site of the disease is usually 
the inner side of the cheek ; either one or both sides may be involved. 
The gangrenous process usually begins as a small, inflamed, in- 
filtrated area in the mucous membrane opposite the teeth. Destruc- 
tion of tissue, distinctly localized, follows and extends with great 
rapidity, the tissue sloughing away in masses. The parts for 
some distance around the ulcer are hard, infiltrated, and discolored, 
presenting an inflamed edematous look. After two or three days 
a discolored, ecchymosis-like area will be noticed on the outer side 
of the cheek, corresponding in location to the gangrenous process 
within. At this point the ulcer soon perforates. The destruction 
of tissue continues quite symmetrically around the ulcer until the 
whole cheek is destroyed. The gangrenous process not infrequently 
involves the bony structure, causing necrosis of the jaw with a 
loosening and falling out of the teeth. A symptom which will 
never fail, and can never be forgotten by one who has seen even 



bednar's aphtha 237 

one of these cases, is the almost unbearable stench which emanates 
from the patient. When the hands or the fingers of the physician 
or nurse come in contact with the gangrenous slough, it is well- 
nigh impossible to remove or neutralize the disgusting odor. The 
disease usually occurs in weakly, marantic children, who generally 
die from exhaustion and sepsis in ten days or two weeks from the 
onset of the disease. 

Treatment. — The treatment pursued has been the use of free cau- 
terization with nitric acid, chemically pure, and disinfectant wet 
dressings of bichlorid i : 2000 ; a saturated solution of boric acid ; or 
equal parts of alcohol and water. The latter is apparently more effec- 
tive in staying the progress of the disease than is either the bichlorid 
or the boric acid solution. On account of the rapid evaporation, 
it should be applied on two or three layers of hnt and covered with 
rubber tissue. Even then it requires very frequent renewals. Hy- 
drogen peroxid may be used to cleanse the ulcer, both before and 
after perforation. Hemorrhage is rarely a complication. The 
disease is usually fatal, even under the best management. 

BEDNAR'S APHTHA 

What is known as "Bednar's aphthae" is not an aphtha, but 
an ulcer. Among the many cases I have seen, not one was in a child 
over four months of age. It is most often seen in poorly nourished 
children. 

The disease, when well developed, consists of a " punched-out '' 
appearing ulcer which is seen on the hard palate, usually, but not 
invariably, at its posterior portion. I have in but one case seen two 
ulcers present at the same time — one on either side of the mesial line. 
As a rule, the process is limited to one side of the hard palate. All 
the cases seen by me were in bottle-fed children, usually those fed 
with a long nipple, or those using a "pacifier," a cork-plugged 
nipple, or some other sucking apparatus. The cases always 
appeared to be due to a prolonged mechanical irritation. The 
ulcer caused no other symptoms than interference with feeding. 
The patient is usually brought for treatment for this reason. 
The child appears lively, but refuses the bottle after an attempt 
at nursing. The mother examines the child's mouth, discovers the 
ulceration, and brings the child with a stor}^ of an inability to 
take the bottle. An examination of the mouth shows the presence 
of the characteristic ulcer. 

Treatment. — As short a nipple as is practicable should be brought 
into use, or, what is better, the child may be fed with a spoon for a few 
days, for as long as the local irritation is continued improvement is 
impossible. The local treatment consists in washing the mouth with 
a saturated solution of boric acid (see page 236) after each feeding, 
and the application to the ulcer once daily of a 50 percent solution 



238 the: mouth, throat, and NOSK 

of nitrate of silver. This is best accomplished by means of a tooth- 
pick, one end of which is wrapped with absorbent cotton, the child 
resting on its back on the nurse's lap or on a table. The nurse 
holds the child's arms to its side while the physician, with his left 
hand, separates the jaws with a spoon or a tongue-depressor, and 
with his right, the child being thus under perfect control, the appli- 
cation can easily be made. The ulcer should thus be treated daily 
for four or five days until it has healed. 

FISSURES OF THE LIPS 
Deep cracks and fissures in the lips are of quite frequent oc- 
currence among out-patient children. Usually the lower lip is 
involved, and in many of the cases there will be but one deep fissure 
and that about the middle of the lower lip. Marasmic, ill-condi- 
tioned children are the most frequent sufferers. The fissures bleed 
easily and occasion considerable pain while nursing. As a result, 
less food is taken than the child requires. If the fissure is a deep 
one, it will be well to apply a 50 percent solution of nitrate of silver 
at the commencement of the treatment. This is to be followed 
by frequent applications — three or four times daily — of a 25 per- 
cent solution of ichthyol. Healing is usually prompt, requiring 
but a few days. If the mucous membrane of the lip generally is 
dry and fissured, as in cases of prolonged illness with fever, the fre- 
quent use of a 5 percent boric acid ointment, made with cold-cream 
as a base, will be of material assistance in controlling the condition. 

ULCERATIONS AND FISSURES AT THE ANGLE OF THE MOUTH 
Ulcerations and fissures at the angle of the mouth are by no 
means uncommon in delicate and marasmic infants. While ulcera- 
tion in this location is one of the manifestations of congenital 
syphilis, such ulcers are not necessarily syphilitic. The condition, 
however, is of sufficient importance to require treatment, because 
the affection is so painful as to prevent the taking of adequate 
nourishment. Painting the fissure with a 25 percent solution of 
ichthyol every three hours during the day will insure the prompt 
healing of the fissures. 

ULCER OF THE FRENUM OF THE TONGUE 

An ulceration of the frenum of the tongue, "the tongue bridle," 
is rarely seen in well children. It is rounded, grayish in appearance,, 
with a sHghtly raised border. It usually occurs in infants who 
are suffering from whooping-cough, bronchitis, or bronchopneu- 
monia. It is never seen except in children who have the lower 
incisors well through, the ulceration being due to contact of the 
frenum with the sharp teeth during the protrusion of the tongue 
in coughing. The ulceration may cause some difficulty in nursing; 



GEOGRAPHIC TONGUE. TONGUE-TIE 239 

it may be necessary to feed the child with a spoon for a day or two; 
the condition is, however, rarely of a serious nature. 

The presence of the ulcer is usually discovered by the mother 
while attending to the mouth toilet. The application of a 50 per- 
cent solution of the nitrate of silver and the use of a saturated 
solution of boric acid as a mouth- wash after each feeding will quickly 
relieve the condition. 

GEOGRAPHIC TONGUE 

The condition known as a "geographic tongue" consists of 
smooth, distinct, reddish patches on the tongue's surface, the areas 
being surrounded by a light grayish, narrow, raised border. The 
smooth surfaces comprising the involved areas are devoid of epi- 
thelium; the borders are composed of hypertrophied papillae which 
take on a grayish color, making a distinct framework for the reddish 
areas, which are almost always crescentic in shape. This peculiar 
marking has given rise to the term "ringworm of the tongue." 
Geographic tongue is seen most frequently in children under three 
years of age, and occurs as often among the strong and vigorous 
as among the delicate and weakly. The condition is usually dis- 
covered by the mother, who, with much agitation, brings the child 
to the physician. It does not appear to be due to and is usually not 
associated with any disturbance of the gastro-enteric tract. The 
portion of the tongue which is not involved appears perfectly normal. 

Treatment of geographic tongue is unnecessary, as it causes 
no symptoms and apparently is independent of any disease. It 
is my custom to assure mothers that the condition is of no con- 
sequence. It usually disappears in a few months. I have known 
a case to last for a year. 

TONGUE-TIE 

Tongue-tie is a condition caused by the extension of the frenum 
forward, nearly if not quite to the tip of the tongue. It interferes 
somewhat with nursing if the milk is hard to draw, and interferes 
generally with the free action of the tongue. 

The treatment consists in dividing the frenum with curved 
scissors. The child is wrapped in a large towel binding its arms 
to its sides. It is placed on its back on the nurse's lap or on a 
table. It is best controlled w^hen supported by the nurse with its 
head between the physician's knees. The head can thus be steadied, 
leaving both hands free for the operation. A grooved director, 
while not necessary, makes the operation safe and easy. The frenum 
is fixed in the slit in the broad end of the director which rests against 
the tongue. This raises the tongue and puts the frenum on a ten- 
sion, and the division with the curved scissors is. a simple matter. 
Bleeding is usually so slight that it need not be considered. 



DISEASES OF THE RESPIRATORY TRACT 

TAKING COLD 

By ''taking cold" we understand that through the influence 
of cold there is produced upon some portion of the skin an impres- 
sion similar to that of shock. This impression affects the entire 
body and manifests itself most frequently in the form of a conges- 
tion of the mucous membrane of the respiratory tract, between 
which and the skin there seems to be an intimate connection. Micro- 
organisms play an important role in the process. They are found 
in large numbers on the diseased mucous surfaces. The changes 
in the mucous membrane resulting from exposure prepare it for 
their growth and development. ''Taking cold " means previous 
exposure, and what will constitute a sufficient degree of exposure 
in one child may produce no effect in another. According to my 
observation the most frequent cause of colds in infancy is the 
effect of cold air on a moist skin. The child that perspires readily, 
or the child that is made to perspire by unsuitable clothing, suffers 
most in this respect, during the cold season. 

I look upon inadequate head-covering as a most frequent cause 
of diseases of the respiratory tract in the young. Usually in the 
country during cold weather, an infant is dressed for the daily outing 
in a warm room with the temperature ranging from 70° to 80° F. 
He is wrapped in ample coats, blankets, and leggings. The child 
is active, throws his legs and arms about, and the dressing thus 
far having consumed considerable time, he perspires freely, but 
still the dressing is not completed. On the head is placed one 
of the more or less artistically decorated airy creations which are 
sold in the shops as children's caps. They furnish little protection 
for the many square inches of the almost bald little head. The child 
is taken out of doors while the wind is blowing and the result is a 
cold, and how it came about is never understood ! He was supposed 
to be dressed ideally for cold weather. The notion is common, 
and to a certain extent proper, that a child's head should be kept 
cool. This theory, however, gives rise to carelessness as to the 
head-dress. During the colder months, as an extra protection, I 
advise mothers to make a skull-cap of thin flannel, for the child to 
wear under the regular outing cap. 

Allowing a child to sit on the floor during the winter months 
is probably the next most frequent cause of his taking cold. Kick- 
ing off the bedclothes at night is another frequent cause. Taking 

240 



ACUTE RHINITIS 24 1 

the child from a warm room through a cold hall is not without 
danger. Holding the child for a few moments by an open window 
during the cold weather is often followed by croup, bronchitis, 
or pneumonia. The uneven temperature of the living-rooms and 
sleeping-rooms in many of our apartment homes is a very common 
cause of cold. Frequently during the day the temperature will 
be between 75° and 80° F., but at night, when the fires are banked, 
it falls to 55° or 60° F. or lower. The child went to bed perspiring, 
kicked off the bedclothes, the temperature in the room fell, the 
body became chilled, and the child took cold. The temperature 
of the living-room should range from 70° to 72° F., the sleeping- 
room from 60° to 65° F. Of course, it will be impossible to keep 
the temperature at all times at these figures, but the closer we 
approximate to them, the safer the child will be. In many instances, 
colds in infants are attributed to the bath. Among dispensary 
mothers this is often considered a cause of cold. I have never 
known a cold to be due to a bath, although, of course, when care- 
lessly given, such a thing is possible. 

Among rachitic and rheumatic children there is a marked pre- 
disposition to catarrhal affections; they acquire laryngitis and 
bronchitis upon very slight provocation. Adults and "runabout '* 
children with coughs and colds should not come in contact with 
infants. There is undoubtedly an element of contagion in such 
cases. It is a very bad practice to have a "family pocket-handker- 
chief." The youngest infant is entitled to a handkerchief inde- 
pendent of the other children, and one handkerchief should never 
do service for more than one individual. Children should not be 
allowed to sit on the floor during the winter. They can have their 
playthings on the bed, on the sofa, or, for those under one year, 
in a clothes-basket which may be raised on two thick pieces of wood 
or a couple of books. There is always a draft near the floor. The 
"pen " referred to on page 38 is the best scheme that I know of 
for keeping children from the floor. 

The room in which the child is dressed for an outing should not 
be above 70° F., better below it. Securely pinning bed-blankets 
to the mattress, or preferably a combination suit with "feet," will 
do much to prevent taking cold at night. 

ACUTE RHINITIS (CORYZA? SNUFFLES; COLD IN THE HEAD) 
Acute rhinitis is a very common ailment throughout childhood. 
Newly born babes, "runabouts," and school-children are alike 
sufferers. The onset is usually sudden, with sneezing and with diffi- 
culty in breathing through the nose. This may continue for a few 
hours, in some cases for a day or two, when a mucous, waterv, nasal 
discharge appears. On account of its interference with nursing, 
infants are the greatest sufferers ; breathing, which has to be carried 



242 DISKASKS OF THK RESPIRATORY TRACT 

on largely through the mouth, is difficult, and nursing, in consequence, 
frequently interrupted. There may be a degree or two of fever 
at the commencement of the attack, but, as a rule, it lasts only a 
few hours. Neglected cases sometimes become infected with pyo- 
genic bacteria and a troublesome purulent rhinitis results. In 
the majority of the neglected cases, however, and in some of those 
that are well treated, this is the beginning of an inflammatory pro- 
cess which involves successively the fauces, tonsils, larynx, and 
bronchi. Repeated attacks doubtless aid in the production of adenoid 
growths in the nasopharyngeal vault. 

Differential Diagnosis. — Acute simple rhinitis is to be differen- 
tiated from specific rhinitis, which, as is well known, is one of the first 
manifestations of congenital syphilis. When due to syphiHtic infec- 
tion, the condition is uninfluenced by the usual treatment. There is 
no tendency for it to descend and involve the mucous membrane 
of the bronchi. The hoarseness of congenital syphilis is chronic and 
of gradual development. Furthermore, if the rhinitis is due to syph- 
ilis, other signs are present, or will soon appear, which will make the 
diagnosis possible. Measles almost invariably begins as an acute 
rhinitis. The accompanying conjunctivitis, the hard, dry, hacking 
cough, and the characteristic rash soon make the diagnosis possible. 
In nasal diphtheria there is invariably a discharge from the nose 
which may be differentiated from simple rhinitis by the fact 
that the discharge in diphtheria is excoriating in character and is 
often tinged with blood. A diphtheritic discharge may be limited 
entirely to one nostril or may be greater from one nostril than the 
other; while in acute simple rhinitis the amount of the discharge is 
usually the same from both sides. The tendency in acute simple 
rhinitis in a strong child is toward recovery in five or six days. 
When the surroundings are unfavorable, or in delicate, rachitic 
children, active treatment will be required to bring about a prompt 
recovery. 

Treatment. — In the first stage, that of engorgement, much may 
be accomplished in the very young by local measures — menthol, one- 
half grain, dissolved in one ounce of liquid albolene. Of this solution 
three drops are instilled into each nostril every hour by means of a 
medicine-dropper. This treatment alone will reHeve the patient of 
a distressing obstruction, thus opening the way to freer breathing. 
In older children a spray containing one grain of menthol to an 
ounce of liquid albolene may be used at intervals of two or three 
hours. 

In case menthol and albolene are not at hand, melted white 
vaselin may be used in the same way. 

For internal use the following medication has served me well: 



ACUTE RHINITIS 243 

For a child three months of age : 

I^. Tincturae belladonnae . gtt.^ vij 

Pulveris camphorae gr. iv 

Sacchari lactis, q. s. 

M. div. et ft. tablets No. xxx. 

Sig. — One tablet every two hours. 

Six months of age: 

I^. Tincturae belladonnae gtt. x 

Pulveris camphorae gr. v 

Pulveris Doveri gr. iv 

Sacchari lactis, q. s. 

M. div. et ft. tablets No. xxx. 

Sig. — One every two hours in water. 

From one to two years of age : 

I^. Tincturae belladonnae gtt. xv 

Pulveris camphorae gr- vj 

Pulveris Doveri gr. x 

M. div. et ft. tablets No. xxx. 

Sig. — One every two hours. 

At least six doses should be given in the twenty-four hours. 
From two to four years of age: 

I^. Tincturae belladonnae. gtt. xv 

Pulveris camphorae gr- vj 

Pulveris Doveri gr. xv 

Sacchari lactis, q. s. 

M. div. et ft. tablets No. xxx. 

Sig.— One every two hours. 

If for any reason the tablets cannot be prepared, powders will 
answer the purpose equally well. 

The above prescriptions are indicated for the second or catarrhal 
stage, a condition in which we usually find the patient when brought 
for treatment. In their use we must guard against the constipa- 
ting effects of the camphor and the Dover's powder. 

I would warn here against the forcible use of the syringe in 
the treatment of nasal disorders, or any form of nasal irrigation 
with any of the saline solutions which requires force for its use. 
Infection is easily carried into the eustachian tubes which may be 
the starting-point of very grave complications, a suppurative otitis 
being thus very easily produced. 

Mothers should be instructed to use an enema of warm sweet- 
oil or soapsuds if the bowels do not move once in twenty-four hours. 
In children of a markedly constipated habit the Dover's powder 
may be omitted. Internal medication, if begun early and properly- 
carried out, will not be needed for more than two or three day .. 
During an attack of acute rhinitis, the child should not be unneces- 
sarily exposed to cold, as there is a strong tendency for the disease 
to descend and involve other portions of the respiratory tract. 



244 DISEASES OF THE RESPIRATORY TRACT 

CHRONIC RHINITIS; NASAL CATARRH 

A nasal discharge, more or less constant, is present in not a few 
children during their entire child life. In the majority this dis- 
charge begins with the onset of cold weather and lasts until spring. 
It may be composed of thin, watery mucus, or it may be muco- 
purulent in character. 

It may be due to several causes, which will be given in the order 
of their frequency ; for, in order to treat this condition successfully 
the source of the discharge must be discovered : 

1. Adenoids in the nasopharyngeal vault. 

2. Hypertrophy of the turbinated bones, with septal deviations, 
and hypertrophy of the mucous membranes. 

3. Infection due to pyogenic bacteria. When present it may 
follow an acute rhinitis, but it is more often the sequel of one of 
the infectious diseases. The discharge may be distinctly purulent 
and is often very profuse. 

4. Infection due to the Klebs-Loeffler bacillus. I have seen 
a great many cases in children from early infancy to eight years of age 
in which there was a serous discharge from one or both nostrils, which 
had persisted for a considerable period of time, in one for an entire 
year. Examination of the discharge showed it to contain the Klebs- 
Loeffler bacillus. These children were not ill, and were brought to us 
for the discharge alone. Such cases do not clear up under the ordinary 
methods of treatment, but promptly respond when from 1500 to 
2000 units of diphtheria antitoxin are given. 

5. With hay-fever there is a periodic discharge which may be 
said to be chronic in character, extending over several weeks. 

6. Malnutrition. A thin, watery discharge apparently due to 
relaxed mucous membranes is seen in weak and poorly nourished 
children, with no other symptom to explain the trouble except 
the general weakness. 

7. Foreign bodies. A foreign body in either nostril will produce 
a persistent discharge. When a child is brought to me with a 
history of a persistent serous or purulent discharge from one nostril, 
I invariably examine for a foreign body, and repeatedly I have 
found this discharge explained by the presence of a pea, a bean, 
a piece of coal, or a button. A few weeks ago at the out-patient 
department of the Babies' Hospital, a child three years of age was 
brought in because of a persistent right-sided nasal discharge 
which had existed for seven months. Examination showed that 
there was a foreign body well up in the nostril. This was removed 
with considerable difficulty and proved to be a piece of cork. 

In these cases of chronic rhinitis the possibility of adenoids 
(see page 448) should never be forgotten; for they cannot be 
excluded because a child is not a mouth-breather and does not 



RECURRENT CORYZA AND ANGINA 245 

snore. Given a child with a chronic, so-called "cold in the head," 
and you will almost invariably find a child with adenoid vegetations 
in the nasopharyngeal vault. Examination may reveal the naso- 
pharyngeal space blocked by the growth, so that the entrance with 
the finger is almost impossible, or there may be but a small pulpy 
mass, or a ridge or soft, friable growth at the upper portion of the 
vault, not large enough to produce signs of obstruction, but, actively 
secreting, it proves to be the source of the discharge. Children 
who have anterior nasal defects, such as hypertrophies of bone or 
thickening of the membranes, will usually have adenoids as well. 
In fact, adenoids play no small part in most of the catarrhal affec- 
tions of the upper respiratory tract in children, and an examination 
of a child with a nasal discharge or a cough which is difficult to 
account for, is never complete without an exploration of the naso- 
pharyngeal vault. 

Treatment. — The treatment consists in correcting the condition 
which causes the discharge. If adenoids are present in a sufficient 
amount to cause trouble, they should be removed (page 449). No 
other treatment is of any avail. For deformities and hypertrophies 
of the anterior nasal structure, operative measures are also essential, 
but should be carried out by one skilled in rhinoplastic work. Puru- 
lent rhinitis, primary or following the infectious diseases, is best 
treated by a spray composed of liquid albolene, one ounce, ichthyol 
ammonia sulphate, two grains, which should be thoroughly shaken 
before using. This should be used as a spray every two hours 
while the child is awake. Once or twice a day it may be well, if 
the secretion is profuse and purulent, to instil into the nostril about 
20 minims of a one-to-six aqueous solution of hydrogen peroxid. 
If the Klebs-Loeffler bacillus is present, antitoxin alone will control 
the disease, and that very promptly. 

The anemic and malnutrition cases, which show almost no ab- 
normality, but suffer more or less from a constant serous discharge, 
are benefited by constitutional measures only — a dry cHmate, plain, 
nourishing food, iron, cod-liver oil, massage, and salt baths. Their 
management is referred to in detail under The Management of 
Delicate Children (page 148). In these children, local treatment 
other than that of cleanhness is a loss of time and energy. The 
operation for the removal of adenoids, the treatment of hay-fever, 
and the methods of removing foreign bodies from the nostrils are 
all referred to under their respective headings. 

RECURRENT CORYZA AND ANGINA 
Occasionally we see patients in whom there is a history of fre- 
quent so-called "colds" with fever, profuse nasal discharge, and 
sore throat. Several attacks occur each winter and usually two 
or three during the summer months. Adenoids probably were 



246 DISEASES OF THE RESPIRATORY TRACT 

present originally and possibly enlarged tonsils; but after their 
removal the attacks persisted, though perhaps they were less fre- 
quent and less prolonged. Still the tendency to coryza was by 
no means obviated and the parents are vigorous in their denuncia- 
tion of the operator and adenoid operations in general. 

These cases are of the same type as those of recurrent bronchi- 
tis, and the suggestions under that head (page 274) will be the best 
for us to follow here. 

NASAL HEMORRHAGE 

Nasal hemorrhage in a child is usually due to one of two sources — 
adenoid vegetations in the nasopharyngeal vault or an erosion or 
ulceration of the mucous membrane covering the free vascular 
area of the anterior portion of the nasal septum. 

Treatment. — When the hemorrhage is due to an adenoid growth, 
it is usually readily controlled by keeping the child in an upright 
position, or by the application of cold to the back of the neck — pref- 
erably by a piece of ice wrapped in a table napkin or by an ice-bag. 
When the hemorrhage is due to an erosion of the septum, pressure of 
the finger on the outer side of the bleeding nostril will effectually 
control it, or the nostril may be packed with cotton saturated with a 
5 percent solution of antipyrin or a i : 2000 solution of adrenalin. 

For permanent relief, and to prevent a recurrence of the hem- 
orrhage, adenoids should be removed and an excoriated or ulcerated 
septum cauterized with a 50 percent solution of silver nitrate. 
If the ulcer is first cleaned with plain water, ordinarily but one or 
two applications of the silver solution will be required. Spraying 
the affected side with a i percent solution of ichthyol in liquid 
albolene will hasten the healing process. As the ichthyol is not 
soluble in the oil, the mixture should be well shaken before using. 

THROAT EXAMINATION 
In order to examine the throat of a young child quickly and 
thoroughly, it is necessary that he be held in a proper position 
in front of and at the right side of the attendant, supported by her 
left arm, beneath the buttocks. Her right arm, which is thus left 
free, is passed around the child, binding his arms to his sides (Fig. 
22). The child's head rests against the shoulder of the attendant. 
The physician places his left hand on the child's head to steady 
it, and with the tongue depressor or teaspoon in his right hand, with 
the child in perfect control, the tongue is pressed downward so 
that it will not obscure the field of vision. With an older and 
stronger child, it is best to bind the arms to its sides with a large 
towel or small sheet. The most satisfactory view can be obtained 
by dayhght before a window. If the examination is made in the 
evening, a lamp or taper held by a third person, a little above and 



FAUCITIS 



247 



behind the attendant's right shoulder, will furnish a satisfactory 
illumination. The head-mirror should be used for children who 
are too ill to be taken out of bed, the reflection from a Ughted lamp 
or candle being sufficient. 

FAUCITIS 
By the term "faucitis" we understand an inflammation of 
that portion of the mucous membrane of the buccal cavity situated 




Fig. 22.— Examination of the Throat. 



posteriorly to the soft palate and the anterior pillars of the fauces, 
including both the anterior and posterior pillars, the tonsils, and 
the pharyngeal wall. The inflammatory process is superficial, in- 
volving the mucous membrane only, so that the tonsils are involved 
only to the extent of the mucous membrane. 

Faucitis is alwa^'s present in scarlet fever, usually to a marked 



248 DISEASES OF THE RKSPIRATORY TRACT 

degree. In measles it is also present, but it is less intense in its 
manifestations. Its most frequent appearance is in connection 
with a summer cold. Every year in late May and June I am called 
upon to treat a great many such cases. There is always cough, 
dry and ineffective, with a slight fever, from 100° to 101° F. The 
child complains of sore throat and there is some discomfort in swal- 
lowing. Upon inspection, an intense inflammation will be noticed 
involving the entire visible mucous membrane. In many cases 
the inflammation extends downward and involves the larynx, which 
will be indicated by the hoarse, croupy character of the cough. 
The entire illness is ordinarily of three or four days' duration. 

Treatment. — The condition is best relieved by a purgative of 
rhubarb and soda — 3 grains of powdered rhubarb and 3 grains of soda 
for a child from two to five years of age. For a child under two 
years of age i to 3 grains of rhubarb and i to 2 grains of bicar- 
bonate of soda may be given. This in a child from one to three 
years of age is followed by a tablet or powder of tartar emetic 9^ 
grain, powdered ipecac ^1^ grain, and chlorate of potash i grain, at two- 
hour intervals. Older children, three years and over, receive 2 to 3 
grains of chlorate of potash, -9V grain of tartar emetic, and 4V grain 
of ipecac at two-hour intervals — six doses in twenty-four hours. 

PHARYNGITIS 

Inflammation limited to the posterior pharyngeal wall is of 
rather infrequent occurrence in young children. When present, 
the parts present a reddened, granular appearance. In the cases 
which have come under my observation, such a condition has always 
been associated with digestive disturbances. The tongue is usually 
coated and the breath foul. A dry cough and frequent attempts 
at clearing the throat are the usual symptoms. The temperature 
is rarely above 101° F. It is to be distinguished from the pharyn- 
gitis which occurs as a result of exposure, in that only the posterior 
wall is involved, the adjacent structures remaining unchanged. 
Thus the tonsils and pillars of the fauces and the soft palate present 
a normal appearance. 

The treatment is to reduce the diet for a- few days to cereal 
gruels, — barley, rice, or wheat, — or to chicken or mutton broth. 
Calomel, y^ grain with one grain of rhubarb after feedings, three 
times a day for three days, will promptly relieve the condition. 

TONSILLITIS 
The onset of tonsillitis is usually sudden. There may be a chill, 
and in a few of my cases an attack has been ushered in by convul- 
sions. However, the usual mode of onset is with fever, 101° to 
103° F., lassitude, loss of appetite, and muscular soreness. Young 
children may show difficulty in swallowing and older children may 



TONSILLITIS 249 

complain of pain in the throat. Not every case of tonsilUtis, 
however, is associated with pain in the throat. Inspection re- 
veals the tonsils swollen and reddened, covered perhaps with light 
colored, cheesy deposits scattered over the surface. In some in- 
stances the disease limits itself to swelling and redness; in others 
the cheesy deposit is an early symptom. The exudative areas 
may remain distinct and single or they may coalesce, forming a 
pseudo-membrane. The duration of the disease ordinarily is from 
three to five days. During the attack the patient feels ill, and often 
the prostration is considerable. There may be a slight swelling 
of the lymphatic glands at the angle of the jaw, but this is usually 
absent. If there is a great deal of tenderness of the glands with 
a sore throat, it is a suspicious sign, and should make one examine 
very carefully for diphtheria. Children of rheumatic inheritance and 
those who have had rheumatism usually suffer from repeated attacks 
of tonsillitis. 

Differential Diagnosis. — Tonsillitis must be differentiated from 
tonsillar diphtheria, and there are few harder problems to solve ; in 
fact, in many cases, early in the attack, the solution is impossible 
without a bacterial examination. The following characteristics of 
the average case of the two diseases may aid us in differentiating. 

Tonsillitis. — Onset sudden; fever high at onset, 102° to 105° F. 
Glands at the angle of the jaw slightly swollen, if at all. Exudation, 
follicular, appears as small dots; membrane may form through 
coalescence. 

Tonsillar Diphtheria. — Onset gradual; fever usually low at 
onset, 100° to 102° F. Lymphatic glands at the angle of the jaw 
considerably swollen; membrane present on the tonsil, appears 
in thin grayish layers which gradually become thicker and more 
extensive. 

Mixed Infection. — A case of mixed infection may present at 
first a picture of a typical tonsillitis. The temperature may vary 
from 103° to 105° F. There is pain upon swallowing, prostration, 
and loss of appetite with a follicular exudation. The case remains 
stationary for from twenty-four to forty-eight hours, when 
the dots coalesce, forming a firm membranous deposit, the lymph- 
nodes at the angle of the jaw enlarge, and, in short, both the clinical 
manifestations and the bacterial examination show that we have 
to deal with a case of diphtheria. 

The cases of diphtheria which are preceded by a clinical ton- 
sillitis are probably the most dangerous. Such a case was primarily 
a tonsillitis and diagnosed as such, and for several days considered 
to be only a tonsillitis, in spite of the membranous deposit which 
formed later. This gives abundant opportunity for the exposure 
of other children, and the delay in making the diagnosis postpones 
the use of antitoxin, rendering the remedy of little or no avail when 



250 DISBASES OF THE RESPIRATORY TRACT 

finally given. It is my rule to consider as diphtheria every case 
in which there is a pseudo-membrane on the tonsils, and to treat it 
with antitoxin without waiting for a bacterial examination. Further- 
more, when there are other children in the family, I invariably quar- 
antine every case of simple tonsillitis. 

Treatment. — Local treatment of the diseased parts in tonsillitis 
by spraying, swabbing, and painting has been of very little service in 
my hands, particularly in children under four years of age. When 
the child is held by force for such treatment, thoroughness is im- 
possible and little or nothing is accomplished. For tractable children 
and those old enough to understand what is being done, gargles, 
sprays, and irrigations are useful in so far as they relieve pain and 
cleanse the diseased parts. A useful gargle is the following: 

I^. Sodii salicylatis 

Sodii biboratis 

Sodii bicarbonatis aa gr. xlv 

Essentiae menthse piperitae 5j 

Aquae q . s. ad 5 ij 

Sig. — One teaspoonful in one-half glass of water at 115° F. Gargle 
entire quantity every hour. 

A useful Spray is the following: 

I^. Acidi borici ^T* ^ 

Aquae menthse piperitae 5 viij 

M. Sig. — Spray throat every two hours. 

Irrigation of the throat is indicated in tonsillitis not only on 
account of cleanliness, but because of the relief from pain which 
it affords. In severe tonsillitis, with much swelling and the con- 
sequent tension, the pain upon swallowing is often excruciating. 
For the irrigation there are needed a fountain syringe and a 
clean tube for introduction into the mouth. The child may lie 
down or sit up, as preferred. If in the recumbent position, the 
head should be turned to one side, the mouth resting over a 
pus basin, which catches the water as it passes out during the 
irrigation. If it is preferred to give the irrigation with the patient 
sitting erect, a basin held under the chin will catch the water as it 
flows from the mouth. Two pints of a normal salt solution — one 
teaspoonful of salt to a pint of water — at 115° F. is placed in the 
bag, which has previously been warmed. The bag is held two 
feet above the child's head and the solution is allowed to flow 
in a brisk stream against the swollen parts, until at least one pint 
of the solution has been used. The irrigations if they furnish much 
relief may be repeated in from four to six hours. 

It is advisable to begin the treatment with a laxative. One 
grain of calomel in divided doses, one-sixth grain every hour, answers 
weU. The child's food is reduced. If bottle-fed, the milk is given 
one-half strength, one-half quantity of the milk mixture being 



TONSILLITIS 



251 



given with an equal quantity of water. The fever, if high, is readily 
controlled by cool sponging (page 502). 

The only drug which has appeared to me to possess any signal 
value for internal use in tonsillitis is chlorate of potash. One grain 
at two-hour intervals for a child one year of age; 2 grains at two- 
hour intervals for a child two years of age — 16 grains in twenty- 
four hours; 3 grains for a child three years of age — 24 grains in 
twenty-four hours. I rarely give more than 3 grains at two-hour 
intervals at any age. I have used chlorate of potash in this way 
for several years, and I have never been able to associate the drug 
with kidney complications in one of the hundreds of cases in which 
I have used it. It is usually made in solution with simple elixir 
and water, or syrup of raspberry and water. 




Fig. 2^. — Cold Compress in Position. 



Cold compresses (see Fig. 23) to the throat are of aid in older 
children — those who can appreciate the necessity of the treatment. 
In the young, those under two years of age, it is difficult to keep the 
applications in position. My instructions are to fold and soak a table 
napkin in cold (40° to 50° F.) water. The compress should be about 
2^ inches wide and from four to five thicknesses of the material 
should be used. The water is pressed out and the dressing is placed 
under the jaw, so that the ends reach to the ears. The compress 
is covered with oiled silk or rubber tissue and is held in position by a 



252 DISEASES OF THE RESPIRATORY TRACT 

handkerchief or a piece of cheese-cloth, which passes over and around 
it, and may be tied at the top of the head. It should be removed 
every thirty minutes, wrung out of cold water, and reapplied. When 
the compress is put on, as we often see it, wrapped around the 
neck, it will be of no service, as it does not even touch the 
parts affected. Children who have repeated attacks of tonsillitis 
are put on antirheumatic treatment (page 486) in the intervals 
between attacks. 

HYPERTROPHIED TONSILS 

Chronic enlargement of the tonsils is usually the result of several 
acute attacks of tonsillitis. A tonsil is said to be enlarged when 
it extends beyond the pillars of the fauces. Enlarged tonsils pro- 
duce mouth-breathing, disturbances of speech, and eustachian- 
tube catarrh, and they are doubtless a factor in adenoid etiology. 
Children with enlarged tonsils are also particularly susceptible to 
diphtheria. In the crypts are harbored myriads of bacteria, which, 
under favorable conditions, produce repeated attacks of acute 
inflammation: the pneumococcus, the tubercle bacillus, the Klebs- 
Loeffler bacillus, and many other pathogenic bacteria have repeat- 
edly been found in the tonsillar crypts. Children of rheumatic 
inheritance are very apt to have enlarged tonsils. 

Treatment. — The treatment consists in removal — excision (see 
page 448). Sprays, gargles, and local applications are of little or no 
avail. When, for any reason, the operation is not possible, cauteriz- 
ing with a galvanic cautery is indicated. Several sittings at intervals 
of five or six days will be required, however, to reduce a tonsil of 
any considerable size. Occasionally cases are seen in which the 
tonsils are broad and fiat, with marked increase of connective 
tissue and dilated crypts ; in such cases when the tonsil is not large 
enough to be removed with a tonsillotome the tonsil punch or 
the cautery may be brought into use. A few sittings will prac- 
tically remove the tonsil, and its possibilities as a culture-field for 
pathogenic bacteria are destroyed. The application of a 5 percent 
solution of cocain on a swab will render the cauterization com- 
paratively painless. 

Hypertrophied tonsils should be removed for two reasons: (i) 
their obstruction to respiration, and (2) their capacity for har- 
boring all sorts of bacteria, among which the tubercle bacillus and 
the Klebs-Loeffier bacillus are the most important. 



PERITONSILLAR ABSCESS? QUINSY 
The seat of a peritonsillar abscess is in the cellular tissue about 
the tonsil. It may be above, in front of, or behind the tonsil. The 
disease is seen rather infrequently in children. I have seen but 



PERITONSILLAR ABSCESS; QUINSY 253 

one case in a child under six years of age. It usually follows a 
tonsillitis. In none of my cases has it followed diphtheria, scarlet 
fever, or measles. The history is usually as follows: 

The child has a tonsillitis with the usual symptoms, with the 
addition of greatly increased swelling and pain upon swallowing. 
He complains of pain in the muscles of the neck on the affected 
side, the head being held toward that side. A fairly early symp- 
tom is inability to open the mouth to the usual extent. In the 
average case, inspection reveals a reddened, edematous swelling 
slightly above and in front of the tonsil, causing a forward displace- 
ment of the uvula. In a few instances I have seen it develop behind 
the tonsil, in which case the tonsil on the affected side will appear 
unduly prominent. This type of case is very apt to be overlooked 
unless a digital examination is carefully made, when a soft, fluc- 
tuating swelling will readily be felt behind the tonsil. 

Treatment. — The treatment is by incision. This, however, should 
not be made until the abscess is fully developed. If the incision is 
made too early, it has in my cases invariably closed and required re- 
opening. This closure sometimes occurs even after a timely opera- 
tion, because too small an incision is made and the contraction of the 
abscess wall necessarily following the free discharge of pus and blood 
effectually closes the opening. 

For operation the patient should be wrapped in a large towel 
or sheet to bind the arms securely to the sides. He should sit in 
an upright position on the lap of the attendant, against whose 
right shoulder his head rests. The left arm of the attendant is 
passed around the patient, holding him firmly, while the right hand 
grasps his forehead. A Denhard gag of the O'Dwyer set should 
be used to hold the mouth open. Either by the use of reflected 
light from a head-mirror, or with the patient facing a window, 
the operator, using a guarded bistoury, makes a free incision in 
the abscess from above downward. The escape of a considerable 
amount of blood usually follows the withdrawal of the knife. Often- 
times more blood than pus is discharged. This is particularly 
apt to be the case if the abscess is opened early. 

It is interesting to note that the cases which open spontane- 
ously never heal spontaneously. In addition to a free incision 
it is my custom, during my daily visits immediately after the opera- 
tion, to prevent a closure of the wound by passing into it a director, 
and, by moving it up and down, break up any beginning granula- 
tions. With free, uninterrupted drainage the case is usually well 
in from three to five days. 

Aside from a saline laxative, which should be given early in 
the attack, internal medication is valueless. Two drams of Rochelle 
salts or six ounces of a solution of citrate of magnesia are usually 



254 DISEASES OF THE RESPIRATORY TRACT 

ordered. Other means of treatment are directed to the comfort 
of the patient. An ice-bag appHed externally before operation 
may be grateful to the patient. Our greatest means of furnishing 
relief, however, lies in the use of the hot saline irrigation, and the 
hot gargle where practicable. But few children can gargle well 
enough to make this advantageous, so that ordinarily it is best 
dispensed with. With the few cases where it is practicable, I 
have found the following prescription and method of use of service: 

I^. Sodii bicarbonatis gr. xlv 

Kssentiae menthae piperitae 5j 

Aquae q. s. ad 5 ij 

Sig. — Add 1 teaspoonful to 6 ounces of water at 120° F. and gargle entire 
quantity every half hour. 

The pain occasioned by gargling is another objection to its use 
in children. A far more effectual means of reHeving pain in this 
disease, and one which causes no effort nor distress whatever, and 
which gives astonishing relief, is a saline irrigation which is prepared 
and given as follows: A heaping teaspoonful of salt is added to one 
pint of water at 120° F. This is placed in a fountain syringe which 
is previously warmed. A towel is placed around the patient's 
neck, to protect the clothing. The basin is held under the mouth, 
to catch the drainage. With everything in readiness, the bag con- 
taining this solution being hung from two to three feet higher than 
the child's head, the end of the rubber tube, a part of every foun- 
tain syringe, without the hard-rubber tip attachment, is placed 
in the child's mouth and the hot solution is allowed to flow against 
the inflamed surfaces until the entire pint has been used, pressure 
being maintained upon the tube so that the flow will not be too 
free. For the first irrigation or two, there will be more or less cough- 
ing, and the child may have to rest after an interval of a few minutes. 
After he becomes accustomed to the procedure the entire pint 
may be used without intermission. The irrigations may be repeated 
every hour and may be used as well after as before operation. When 
once the child experiences the relief afforded, there will be no trouble 
in repeating the irrigation. 

RETROPHARYNGEAL ABSCESS; SUPPURATIVE RETRO- 
PHARYNGEAL ADENITIS 

A retropharyngeal abscess is usually a streptococcus infection 

of one or more of the retropharyngeal lymph-nodes which form a 

chain on either side of the median line, posterior to the pharynx 

and between the pharyngeal and the prevertebral muscles. The 

nodes are said to disappear at about the third year of life. It has 

never been my privilege to see a case in a child over three years 

of age. The disease is very liable to be overlooked. Seven of 



RETROPHARYNGEAL ABSCESS 255 

my cases had been treated — and all but one of them treated by 
more than one physician — for something other than retropharyngeal 
abscess. This failure to recognize the affection has been com- 
mented upon by others, recently by Morse, of Boston. It is due 
to two causes: First, pediatric writers in their description of the 
disease have laid down too narrow and definite a symptomatology; 
second, the lack of thoroughness on the part of physicians in the 
examination of their cases results in their failure to discover the 
true nature of the case. 

In describing the disease, writers tell us that the patient holds 
his head in a characteristic position, backward and toward the 
affected side ; that the breathing is noisy and stertorous in character ; 
that there is difficulty in swallowing ; that there are enlarged lymph- 
glands at the angle of the jaw, and that, on examination, a bulg- 
ing of one side of the posterior pharyngeal wall is usually dis- 
covered. Only four of my ca.^es showed the above combination of 
symptoms. All the cases showed but two symptoms in common — 
difficulty in swallowing and changed voice. Other than this the 
cases varied widely, depending upon the location of the abscess. 
Obviously, an abscess situated low down on the posterior pharyn- 
geal wall will not manifest itself in the same way as one high up 
behind the soft palate. 

Illustrative Cases. — A baby nine months of age had been under 
treatment in one of the outdoor clinics of New York city. A diag- 
nosis of adenoids had been made and a day appointed for the opera- 
tion. The mother, wishing to have the diagnosis of adenoids 
confirmed, brought the child to the out-patient department of the 
Babies' Hospital. The symptoms of mouth-breathing, nasal voice, 
and slight difficulty in swallowing had been present for a couple of 
weeks. There was no characteristic position of the head, no rigid- 
ity of the neck, no superficial enlargement of the lymphatic glands. 
Inspection of the throat disclosed a bulging forward of the soft 
palate on the right side. A digital examination revealed a round, 
fluctuating mass, the size of a hickory-nut. It was found high on 
the posterior pharyngeal wall and almost entirely covered by the 
soft palate. No adenoids w^ere present. 

A baby two years of age had been ill for a week with tonsillar 
diphtheria and was thought to be recovering, when suddenly the 
voice became hoarse and croupy, with gradually increasing dyspnea. 
There was both expiratory- and inspiratory obstruction, such as 
we expect in laryngeal diphtheria, and the attending physician, 
an excellent practitioner, naturally concluded that the diphtheritic 
process had extended to the larynx. There was stiffness of the neck 
but no nasal obstruction (see above). There was slight difficulty in 
swallowing. Inspection of the throat with a dim Hght revealed nothing 



256 DISEASES OF THE RESPIRATORY TRACT 

but the enlarged tonsils. I was called to intubate, and finding the 
respiratory obstruction sufficient to require intubation, I proceeded to 
make a digital examination, as is my custom before intubating. I 
was not a little surprised to find a soft, fluctuating mass low down 
in the pharyngeal wall, extending below and pressing against the 
glottis. The abscess was opened, with immediate relief to the 
obstruction. 

A baby, seven and a half months of age, was an inmate of the 
country branch of the New York Infant Asylum during my service 
in that institution.^ My attention was first called to the child 
because of its difficulty in swallowing. There was very little ob- 
struction, but the voice was harsh, hoarse, and croupy. About 
a month previous, there had been a suppurating submaxillary aden- 
itis. On examining the throat, a large abscess was seen on the right 
pharyngeal wall, extending downward as far as could be seen. This 
case was my first experience with retropharyngeal abscess, and 
a Denhard gag of the O'Dwyer set, which should never be used in 
these cases, was introduced and the child held in an upright position 
by the assistant. While feeling for the thinnest point of the sac 
for a suitable place for the incision the child suddenly stopped 
breathing, became limp and apparently lifeless. An intubation 
tube, the smallest of the O'Dwyer set, was quickly introduced with- 
out the gag. After several minutes of artificial respiration, the 
use of oxygen, and free hypodermic stimulation with brandy, respira- 
tion was again established. The first inspiration was so long 
delayed that we had almost given up the case as hopeless, when 
the first short gasp occurred. In half an hour the child had suffi- 
ciently recovered to allow the opening of the abscess. This was 
done without a gag, with the tube in position. After a copious 
discharge of pus, the tube was removed and the child recovered. 
In this case, the suffocation was due, doubtless, to the introduction 
of the gag and the pressure of the finger, which forced the pus into 
the lower portion of the sac, which extended below the glottis, 
where it exerted sufficient pressure to prevent the entrance of 
air. 

A private patient one year old had diphtheria — laryngeal, fau- 
cial, and tonsillar. Under 9000 units of antitoxin and intubation, 
satisfactory progress was made, and on the eighth day of the illness 
the tube was removed. It had to be replaced in a few minutes 
because of returning dyspnea. Upon replacing the tube an abscess 
was found in the right posterior pharyngeal wall, pressing upon and 
extending below the larynx. The presence of the tube had prevented 
the recognition of the abscess, as the voice and breathing were per- 

^ The case was reported at the time by Dr. Henry E. Tuley, assistant resi- 
dent physician. 



RETROPHARYNGEAL ABSCESS 257 

fectly normal. It being decided that this was the cause of the 
obstruction, the abscess was evacuated, but the marked edema 
of the glottis still caused considerable respiratory obstruction, 
and the tube was required for two weeks longer. The child made 
a perfect recovery and is well and strong today. 

The above cases are cited in detail in order that the reader may 
the more fully realize that retropharyngeal abscess may exist with- 
out the so-called "characteristic symptoms," and also to emphasize 
the fact that many cases have been, and will continue to be, over- 
looked until physicians use the finger as an aid to diagnosis in the 
diseases of the upper respiratory tract. It is to be remembered that 
there is no "characteristic breathing" and no "characteristic posi- 
tion " of the head in retropharyngeal abscess. The disease is usually 
secondary to retropharyngeal adenitis, due to infection from ad- 
jacent diseased structures. There is always fever, ioi° to 104° 
F., with loss of appetite. Occasionally the abscess points outward 
and requires external incision. 

Treatment. — The diagnosis made, there is but one means of treat- 
ment — incision and evacuation of the pus. In order to do this it is 
necessary that the child be under perfect control. The arms should 
be bound to its sides with a large towel or a small sheet securely 
pinned. The child is held in an upright position on the lap of the 
attendant, who passes his left arm around the child, while his right 
hand grasps the forehead, drawing the head for further support back- 
ward against the right shoulder. The operation should be performed 
in a good light — either reflected light from a head-mirror or direct 
light from a window. With a tongue depressor in the operator's left 
hand the mouth is kept open, and with the tongue out of the way, 
the right hand is free to make the incision, for which an ordinary 
scalpel is used. The incision should be from above downward and at 
least one-half inch in length. A basin should be in readiness and the 
attendant instructed to invert the child at a word from the operator 
as soon as the incision is made. This allows the pus and blood, 
which, if aspirated into the trachea, may produce fatal results, to 
stream out of the mouth. While the abscess is discharging and the 
head dependent, the clean index-finger of the operator should ex- 
plore the cavity, enlarge the opening, if necessary, and remove 
any necrotic tissue that may be present. The case should be care- 
fully watched for several days, as the opening is liable to close 
before resolution is complete, particularly if it has not been enlarged 
wdth the finger. Recovery is usually complete in from five to seven 
days. 

17 



258 DISEASES OF THE RESPIRATORY TRACT 



RETROPHARYNGEAL ABSCESS (TUBERCULOUS); CARIES OF THE 
CERVICAL VERTEBRA 

The condition is usually described as associated with idiopathic 

retropharyngeal abscess, though it should not be, as the condition 

is a part of and results from tuberculous disease of the spine, which 

will be referred to under the proper headings. 

IRRIGATION OF THE THROAT 

Indications. — In peritonsillar abscess or retropharyngeal abscess 
after operation, in sloughing ulcerative processes in the throat, such 
as we see in diphtheria rarely, but with comparative frequency in 
scarlet fever, irrigation of the throat with hot normal salt solution 
is of distinct therapeutic value. The relief to the pain, particularly 
in quinsy, before operation, is sufficient to warrant its use. Those 
who have treated thus the fetid sloughing throat of scarlet fever, for 
example, need no argument as to its possible advantages. Acute 
suppurative otitis is always due to the throat infection. Gargling 
in children is a measure of very limited usefulness even in those 
who do it well, for the" reason that the solution employed scarcely 
comes in contact with the post-pharyngeal wall and the lateral 
faucial structures. In a great majority of older children, and in 
all young children, it is practically useless so far as the cleansing 
of the deeper faucial structures is concerned. 

Cervical adenitis, acute, persistent, and suppurative, is the 
direct result of throat infection. An important means of preventing 
it, with its distressing consequences, is an effective throat toilet. 
Often in scarlet fever not a small part of the systemic infection 
after the third or fourth day is through the throat. The irrigation 
should be done two or three times a day as follows : 

Operation. — The child is wrapped in a sheet, which is securely 
pinned, binding his arms to his sides. He rests on his right side with- 
out a pillow. Directly under his mouth is a pus basin to catch the 
outflow. A new fountain syringe, containing a hot salt solution, 120° 
F., is suspended about three feet above the child's body. The 
largest size of the hard-rubber rectal tip is fastened to the pipe and 
the tip placed between the child's teeth. The current, interrupted 
every few seconds, should be forcible enough to increase its efficacy 
as a cleansing agent, the volume of fluid being so small that no 
inspiration of the water occurs. 

The first irrigations will arouse more or less rebellion on 
the part of the patient and but one-half pint of the solution 
need be used. In older children no trouble will be experienced after 
the relief afforded by the first injection is appreciated. In refrac- 
tory young children, from two to four years of age, the assurance 
that there will be no pain and a promised reward will reduce the 



ACUTE CATARRHAL LARYNGITIS; SPASMODIC CROUP 259 

struggling to a minimum. It is not to be expected that the child 
will not cough; in fact, a moderate amount of coughing is desirable, 
as it dislodges the pus and sloughing tissue, enabling the solution 
to cleanse the parts more effectually. 

ACUTE CATARRHAL LARYNGITIS; SPASMODIC CROUP 

By acute catarrhal laryngitis we understand an idiopathic ca- 
tarrhal inflammation, involving the lar^mx and the adjacent structures. 
Nervous, rachitic children are particularly susceptible to the disease. 
Adenoids are often a predisposing cause. The onset may be sudden 
or gradual. Cases which are of a gradual onset usually follow an 
acute inflammatory condition of the nasopharynx. At first there 
is usually a catarrhal rhinitis, the fauces and larynx becoming suc- 
cessively involved, requiring two or three days, perhaps, before 
the laryngitis is well marked. The temperature is usually not high 
at the onset. One of the early symptoms indicating laryngeal 
involvement is a hard, dry cough, croupy and "barking " in char- 
acter. The croupy element in the cough increases in severity to- 
ward evening. 

In the cases with sudden onset, the child retires at the usual 
hour in apparently good health; a few hours later he wakes with 
a characteristic cough. Whether the case is of sudden or gradual 
onset, the care is practically the same after the cough develops. 
Many cases stop at this point. There is a severe cough for a few 
days which subsides under proper treatment. For a few of the 
cases, however, the course is not so favorable; the cough continues, 
becoming stridulous, every inspiration being accompanied by a 
loud crowing sound. Occasionally a case will be seen wdth marked 
laryngeal obstruction, due to the swelling and laryngeal spasm, 
that will require intubation. In my experience, however, this 
is very rare, as I have had to intubate but one child with catarrhal, 
non-membranous croup — an infant sixteen weeks old. 

Acute laryngitis may be confused with diphtheritic or mem- 
branous laryngitis. For differentiation, see page 308. 

Laryngismus stridulus may be mistaken for catarrhal laryngitis. 
It is easy to differentiate, when one remembers that there is no 
cough in uncomplicated laryngismus stridulus, and that the laryn- 
geal spasm is usually associated with excitement, fright, or some 
other nervous influence. Further, laryngismus stridulus does not 
occur as a definite illness, the laryngeal spasm, mild or severe, 
occurring, as a rulef several times a day, covering a period of weeks 
or months. The continued obstruction, always associated with in- 
flammatory conditions of acute catarrhal laryngitis, is absent. 

Treatment. — In the treatment of catarrhal laryngitis in children, 
two factors must be kept in mind: First, the congestive infiltration 



26o DISKASKS OF THK RESPIRATORY TRACT 

and dryness of the parts, which cause the metalHc cough and the 
stridulous breathing; second, the laryngeal spasm, which is purely 
a nervous manifestation, due, doubtless, to the irritation of the ter- 
minal filaments of the recurrent laryngeal nerves which supply the 
larynx. 




Fig. 24.— Crib Prepared for Steam Inhalation. 

Not in every case of laryngitis in children by any means do 
we have croup. But when croup is present, we know that back 
of it there is laryngeal spasm with congestion and inflammation. 
If we are to treat these cases of catarrhal croup successfully, with 
quick recoveries, we must not lose sight of the nervous element, 
which is considerable. 

Expectorants. — For the simple coughs, without interference with 



ACUTK CATARRHAI. LARYNGITIS; SPASMODIC CROUP 26 1 

respiration, the expectorant and steam treatment answer admirably, 
regardless of the age of the child. This special treatment should be 
preceded by a full dose — from one to three teaspoonfuls — of castor oil. 
For a child under one year of age a tablet composed of tartar emetic 
Y^o" grain with powdered ipecac -gV grain should be given every two 
hours — eight doses in the twenty-four hours. If the tablets or 
powders are not to be had, tw^o drops of syrup of ipecac may be 
given instead. For a child from one to two years of age a tablet 




Fig. 25.— The Holt Croup Kettle. 

or powder composed of y^o grain of tartar emetic, :^ grain of pow- 
dered ipecac, |- grain of Dover's powder at two-hour intervals, 
eight doses in twenty-four hours. After the first day the treatment 
should be commenced early in the morning, so that by evening, 
when the cough and spasm are at their maximum, the full influence 
of the drugs may be felt. From the third to the sixth ^-ear, a powder 



262 DISEASES OF TH^ RESPIRATORY TRACT 

or tablet composed of tartar emetic gro grain, powdered ipecac 3V 
grain, and Dover's powder ^ grain should be given at two-hour 
intervals, eight doses in twenty-four hours. At least eight doses 
of one of the above prescriptions should be given daily, in order to 
get the full benefit of the drugs employed. If the Dover's powder 
produces constipation it may be oniitted, or a laxative may be given ; 
usually the treatment need not be continued more than two or 
three days. In case the attack is mild, it is best to omit the Dover's 
powder. 

Cold Compresses. — In older children a cold compress to the throat 
is a valuable local measure. A napkin or piece of old linen answers 
best for this purpose. It is so folded that there are at least six thick- 
nesses of the material. This is moistened with cold water at 60° F., 
wrung thoroughly, and placed against the neck, under the jaw, so as to 
extend from ear to ear. Over this should be placed a piece of oiled 
silk or rubber tissue, and all held in position by a strip of thin muslin 
or cheese-cloth, which should be brought together at the ends and 
fastened at the top of the head. The compress should be changed 
every thirty minutes. In very young children this treatment is rarely 
satisfactory, for the reason that it is difficult to force the child 
to allow the bandage to remain in place. The practice of placing 
the compress around the neck, as is often done, is of no value, as 
it does not even touch the diseased parts. (See Fig. 23.) 

Steam Inhalations. — Steam inhalations are effective only when the 
patient is kept in an enclosed space. The steaming kettle in the room 
is of little or no service. The easiest and most practical place for 
the child is in its crib, which should be covered with a sheet. An 
open umbrella maybe substituted when a crib is not available. Under 
the umbrella, which rests upon the bed, lies the child, and covering 
all is a sheet which is pinned to the umbrella ; or the umbrella may 
be opened and placed over the baby-carriage and draped as before. 
Any means or apparatus which will furnish steam and conduct it 
to the enclosed space containing the child will answer. The Holt 
croup kettle (Fig. 25) is always to be used when obtainable. The 
steaming may be continued for hours, if required. The sheet should 
be removed occasionally for a few moments, in order to allow a 
change of air. Usually a child is kept under the tent from twenty 
minutes to one-half hour without such a change. The tent is seldom 
so close as to prevent all ventilation. 

Calomel Fumigations. — A quicker and more effectual means than 
steam is the use of calomel fumigations. The patient is placed under 
a tent prepared as above. The Ermold lamp, made especially for this 
purpose (Fig. 26), is recommended, but the ordinary alcohol lamp used 
for warming milk answers every purpose. Ten grains of calomel are 
placed in any tin receptacle, which rests or is held over the flame. 



ACUTE CATARRHAL LARYNGITIS; SPASMODIC CROUP 



263 



Cr~~> 



An ordinary kerosene lamp has served me well in a few instances, 
the calomel being placed in the cover of a lin can which was held 
by a pair of pincers over the top of the lamp chimney. Regardless 
of the method, the fumigation must be constantly watched by 
some competent person, so as to avoid the possibility of igniting 
the bedclothes. When the fumes begin to fill the tent, the child 
will cough considerably. If the cough continues for more than a 
few minutes, it is advisable to allow a portion of the vapor to escape. 
The calomel will be consumed in from 
five to ten minutes, depending upon 
the degree of heat used. After the 
tent is filled with the vapor, allow the 
child to inhale it for about one-half 
hour. The vapor produces a free se- 
cretion from the mucous membrane 
of the parts and a local depletion, 
with enlargement of the lumen of the 
larynx and consequent relief of the 
symptoms. The fumigation may be 
repeated after an interval of two or 
three hours. In a non-diphtheritic 
case I have rarely had to repeat the 
inhalations more than two or three 
times. 

Antispasmodics. — In the cases of 
sudden onset, in which the spasmodic 
element is prominent at the commence- 
ment of the attack as indicated by the high-pitched crowing inspira- 
tion, and in some extreme cases by the struggle for breath, the cyano- 
sis, the stridor, and the infrastemal recession, the above treatment 
will not answer. In such cases we must combine an expectorant with 
anti-spasmodic drugs. A full dose of syrup of ipecac — one to two 
teaspoonfuls, or sufficient to produce emesis — should be given at once. 
If vomiting does not take place in twenty minutes, the ipecac should 
be repeated. After emesis has taken place, the antispasmodic reme- 
dies should be brought into use. Antipyrin and sodium bromid are 
especially effective at this stage. Antipyrin appears to have a direct 
sedative action on the nervous mechanism of the larynx. To a child 
two years of age the following prescription is often given: 




F1G.26.— Ermold's Lamp. 



M. 



Antipyrini gr. j 

Sodii bromidi gr. ij 

Syrupi ipecacuanhse vjiij to iij 

Aquas q. s. ad oj 

Sig. — Give one such dose every two hours — eight doses in twenty- 
four hours. 



264 DISKASKS Olf THE RKSPIRATORY TRACT 

To a child from three to six years of age may be given: 

I^. Antipyrini gr. ij 

Sodii bromidi gr. iv 

Syrupi ipecacuanha gtt. iij 

Syrupi rhei gtt. xv 

Aquae q. s. ad oj 

M. Sig. — Give one such dose every two hours — eight doses in twenty- 
four hours. 

The medication and other treatment are to be discontinued as 
soon as the dyspnea ceases. 

LARYNGISMUS STRIDULUS 

Laryngismus stridulus is a spasm of the larynx occurring most 
frequently in infants. It is rarely seen after the first year. The 
spasm may cause a partial or complete closure of the glottis. 

The severity of the symptoms depends entirely upon the degree 
of the spasm. In the mild cases, sudden inspiratory effort, as in 
coughing or crying or from fright, will be sufficient to bring on an 
attack. The child gives vent to a long-drawn inspiratory crow 
similar to a whoop in pertussis. This may be followed by apnea 
which lasts for a few seconds, during which time the child becomes 
blue in the face. This is soon succeeded by a series of short gasps, 
and normal respiration rapidly returns. In the more severe and 
rarer cases, the spasm occurs without warning. This is particularly 
apt to be the case in the very young — those under six months of 
age. There is a short, quick inspiration and respiration ceases. 
The child becomes blue in the face, struggles for breath, and becomes 
unconscious. In a few seconds there is a relaxation of the spasm, 
accompanied by a loud, inspiratory crow, followed by two or three 
others of gradually diminishing intensity until normal respiration 
is re-estabHshed. 

Predisposing Causes. — Laryngismus, according to my observation, 
invariably occurs in weakly children — those suffering from malnutri- 
tion and rachitis. Among a large number of cases, the majority of 
which were seen in dispensary work, I have never known one in 
which there was not some manifestation of rachitis. The presence of 
adenoids, or any source of irritation of the upper respiratory tract, 
increases the severity of the spasm and the number of the attacks. 
Under properly directed treatment the spasms usually become less 
and less severe, and finally disappear, although several weeks of 
treatment may be necessary. 

Illustrative Case. — A few years ago, a child five months of age came 
under my care on account of difficult breathing, rachitis, and laryn- 
gismus. The attacks were rather infrequent — once every three or 
four days — but they were very severe, and in one of them the child 
died. There was no evidence of enlarged thymus gland in this case. 



LARYNGISMUS STRIDULUS 265 

In another child, three months of age, the attacks ranged from 
twenty to thirty a day, and were controlled only by a gradual im- 
provement in the child's general condition. 

Laryngismus may be mistaken for whooping-cough or catarrhal 
croup, or it may be associated with both of these affections. When 
children with pertussis lose consciousness during a coughing par- 
oxysm, the possibility of laryngismus must be kept in mind. There 
is always a mild laryngeal spasm associated with severe catarrhal 
laryngitis and whooping-cough, and the value of sedatives in these 
disorders is explained by their action in preventing laryngeal spasm. 

Treatment. — Drugs. — The management is divided into two parts: 
the immediate relief of the spasm, and the treatment of the patient's 
debilitated physical condition. From my observation, the most satis- 
factory method of relieving spasm in the mild cases — those in which 
the unconsciousness is of but a few seconds' duration — is by inverting 
the patient and at the same time slapping him on the back. Splash- 
ing cold water in the child's face may be of advantage in some 
cases, but I have found it of but little service. In cases which are 
sufficiently prolonged to resist inversion and slapping on the back, 
a hasty removal of the outer clothing, with alternate hot and cold 
tub-baths, at 60° F. and 1 20° F. respectively, have been successful, 
except in the fatal case referred to, whose death occurred during 
my absence. If recovery is not prompt, intubation or tracheotomy 
should be performed, followed by attempts at artificial respiration. 
Between the attacks, the patient should receive small doses of anti- 
pyrin and sodium bromid. Under six months of age, one-half 
grain of antipyrin and two grains of sodium bromid may be admin- 
istered in one dram of cinnamon-water — six doses being given 
in twenty-four hours. From the age of twelve months to the third 
year, one to two grains of antipyrin with two to four grains of so- 
dium bromid may be administered in one dram of cinnamon-water — 
six doses being given in twenty-four hours. The only disadvantage 
in the use of these drugs lies in the fact that these children almost 
invariably have faulty digestion, w^hich condition may be aggravated 
by the sodium bromid. When this is observed, the bromid is best 
omitted and the antipyrin given alone. Antipyrin apparently never 
produces any unfavorable effects upon gastric digestion. 

Colon medication may be of considerable service in these cases, 
and when indicated, bromid and chloral are our most rehable seda- 
tives. For a child of six months or under, one grain of chloral 
with three grains of sodium bromid may be given in two ounces 
of mucilage of acacia by the bowel; for a child of six to twelve 
months, two grains of chloral and five grains of sodium bromid in 
three ounces of mucilage of acacia ; for a child of twelve to twenty- 
four months, two grains of chloral and eight grains of sodium bromid 



266 DISEASES OF THE RESPIRATORY TRACT 

may be given in two ounces of mucilage ot acacia. The bromid 
and chloral should not be administered oftener than once in six 
hours. 

The method of administration is as follows: A large soft-rubber 
catheter or a small rectal tube should be attached to a Davidson 
syringe and introduced at least nine inches into the rectum so as 
to reach the descending colon. The child should rest on its left 
side with the buttocks elevated on a pillow so that they are higher 
than the shoulders. After the withdrawal of the tube the position 
of the child should be maintained for several minutes in order to 
aid in the retention of the fluid. 

Diet. — ^The dietetic management of debilitated, rachitic children 
suffering from laryngismus is the same as that of other debilitated 
children. (See Malnutrition, page 162.) In general, they should 
be given as high a proteid diet as is compatible with their digestive 
powers. Thus, if there is intolerance of cow's milk given in suit- 
able dilution, there should be no hesitation in advising a wet-nurse. 
Condensed milk or proprietary foods should not be given such a 
child, if better means of nourishment are obtainable. For children 
over one year of age, cow's milk, cereals containing a large amount 
of nitrogen, soft-boiled eggs, beef-juice, and scraped beef should 
form a large part of the diet. Particularly must these children 
be kept free from all sources of excitement, such as loud talking, 
the over-attention of adults, and the rough, active play of older 
children. 

TRAUMATIC LARYNGITIS 

Traumatic laryngitis, while a very rare condition in children, is 
occasionally met with. It may be caused by the inhalation of steam 
or irritating gases or the aspiration of carbolic or other strong acids. 

I once saw a fatal case due to the aspiration of pure carbolic 
acid by a child three years of age who was given a teaspoonful 
of the acid by a five-year-old sister. As soon as it passed her lips 
the child cried and coughed. None of the acid was swallowed, 
apparently, but sufficient was aspirated into the larynx to produce 
intense congestion and sufficient edema to require immediate opera- 
tive measures. The parts sloughed extensively and the child died 
in two weeks from pneumonia, resulting from sepsis. 

Treatment. — No case of corrosive injury to the mucous membrane, 
sufficient to produce congestion and edema with a resulting inspiratory 
obstruction which requires operative relief, should ever be intubated 
except as a temporary expedient, since the presence of a tube will 
invariably cause extensive sloughing. If the case is urgent, trache- 
otomy is the only warrantable operation. In two cases due to irri- 
tating gases — sulphur dioxid in one case and steam inhalation in 



FOREIGN BODIES IN THE LARYNX. 267 

another — the successful treatment was the use of cold applications 
to the neck by means of wet compresses at a temperature of 60° F. 

LARYNGEAL OBSTRUCTION 

Laryngeal obstruction may be either complete or partial, causing 
entire cessation of, or greatly impeded, respiration. As the calls 
upon the physician for aid in these cases are attended with great 
urgency, it is well to bear in mind the conditions which may give 
rise to, or directly cause, laryngeal obstruction. These are referred 
to in detail under their respective headings. In order of frequency 
they occur as follows: 

1. Acute Catarrhal Laryngitis (Catarrhal Croup), page 259. 

2. Membranous Laryngitis (Laryngeal Diphtheria), page 318. 

3. Retropharyngeal Abscess, page 254. 

4. Foreign Bodies in the Larynx, page 267. 

5. Traumatic Laryngitis, page 266. 

6. New Growths. 

7. Laryngismus Stridulus, page 264. 

Acute catarrhal laryngitis, membranous laryngitis, and retro- 
pharyngeal abscess are by far the most frequent causes of laryngeal 
obstruction in children. In children, edema is a very infrequent 
cause of laryngeal obstruction; it is a complication or a sequel 
of other pathologic states; for example, it may result from an 
inflammation accompanying a low^-placed retropharyngeal abscess, 
a traumatic laryngitis after the inhalation of irritating gases, or from 
the aspiration of corrosive fluids or powders. 

FOREIGN BODIES IN THE LARYNX 

Foreign bodies are usually lodged in the larynx by an act of 
sudden inspiration attended by a quick forward movement of the 
head, as in coughing or laughing with a foreign body in the mouth 
or between the teeth. The patient is immediately seized with a 
violent paroxysm of coughing and suffocation, the severity of which 
depends upon the size and shape of the foreign body. 

Inversion of the patient was of no service whatever in the cases 
seen by me. The first thing to do is to introduce into the mouth 
the index-finger, with the hope that a portion of the mass may 
protrude sufficiently to make possible its removal. Should this 
fail, a laryngeal forceps should be brought into use, its introduction 
being guided and guarded by the index-finger. When this is not 
successful, tracheotomy should be performed to relieve the child 
from immediate danger of suffocation, after which further surgical 
procedures may be considered. Intubation, it is hardly necessary 
to state, should not be attempted. 



268 DISEASES OF THE RESPIRATORY TRACT. 



PERSISTENT COUGH 

I have had occasion to examine and treat many children who 
were brought to me because of a "cough" which had not been 
controlled by the measures employed. The history is usually only 
that of a persistent cough. It may be irritating in character, keep- 
ing the child awake at night, or it may be paroxysmal, the attacks 
being more severe when the child is lying down. Many times the 
paroxysms are so severe, being particularly worse at night, that 
whooping-cough is suspected because of the absence of chest signs. 

While we hear much of the cough of teething, the "stomach 
cough," the "nervous cough," and the "habit cough," it has never 
been my lot to see a case in which the cough was not connected in 
some way with the respiratory tract. Thorough examination of these 
cases, perhaps repeated examinations, will be required before the site 
of the trouble is definitely located, when it will invariably be found 
somewhere between the anterior nares and the thorax. The stomach 
cough, the nervous cough, or the teething cough formerly stood for 
the persistent cough which could not be accounted for by physical 
examination of the chest or by mere inspection of the throat. They 
are frequently referred to by the older writers. 

An adherent pleura and enlarged tonsils without adenoids are ac- 
countable for a very small number of these cases. An elongated 
uvula, to which these obscure coughs have also been attributed, is 
very rarely a cause. 

An immense majority of these obscure coughs in children are 
due to adenoid vegetations with or without enlarged tonsils. A 
child with such a cough may have the typical adenoid face, mouth- 
breathing, and other signs referred to (see Adenoids, page 448), 
or these symptoms may be entirely absent. It is the latter type 
of case that is particularly puzzling and apt to be overlooked. On 
account of the absence of mouth-breathing and other symptoms 
of nasal obstruction, the possibility of adenoid vegetations has been 
ignored. In these cases careful inquiry will usually elicit the his- 
tory of frequent colds, or what is styled "catarrh," as there is more 
or less serous discharge from the nose, or the child is said to "take 
cold in the head easily." Digital examination of the nasopharyn- 
geal vault will reveal a fringe of soft adenoid growth at the upper 
portion of the posterior pharyngeal wall, not large enough to pro- 
duce obstruction, but actively secreting. This secretion, if not 
profuse, is partially evaporated in the nostrils, or if profuse, is 
discharged from the nostrils or passes backward over the posterior 
pharyngeal wall, thus provoking cough, when the child is up and 
about. When the child rests on his back, the secretion naturally 
flows over the posterior pharyngeal wall, and a cough is the result. 
Time and again I have relieved the most obstinate cough by curet- 



PERSISTENT COUGH 269 

ting and removing this sponge-like tissue. In one patient, a boy 
two years of age, who had been coughing hard for ten days with 
paroxysms and vomiting, a diagnosis of pertussis had been made 
by a member of the family who had seen many cases of whooping- 
cough, and also by myself. Adenoids were found to be present 
in a slight degree. Their removal was advised, with the idea of 
making the coughing attacks less severe, when, greatly to our sur- 
prise, the coughing ceased at once, not a paroxysm occurring after 
the growth was removed. The cough was due to the adenoid vege- 
tations and not to pertussis. 

Adherent pleura, non-tuberculous, as previously mentioned, is 
occasionally a cause of persistent cough. Autopsies upon children 
dying with diseases other than respiratory often show these pleuritic 
adhesions, which are not suspected during life. A little girl twelve 
years of age was brought to me because of a persistent cough. The 
child was otherwise well and gaining in weight. She had been 
treated with expectorants, cod-liver oil, and the usual medication, 
without avail. The cough remained unchanged and was influenced 
only by opiates. A very careful physical examination revealed 
friction rales, covering an area the size of a half dollar, at the base 
of the right lung adjacent to the spine. They were heard only on 
forced inspiration and had been overlooked in the previous exami- 
nation. It had been diagnosed as a "nervous cough." 

Tracheitis will produce a cough, severe and intractable, with 
no signs in the chest. In these cases, however, there is no chronic- 
ity, the cough being sudden in its development. It is usually 
accompanied by slight fever, and if the child is old enough he will 
aid us by referring to the sense of discomfort and tightness which 
exists over the upper portion of the chest. Sometimes the sensa- 
tion will be described as a burning, which is located directly over 
the trachea. 

The most frequent cause of the temporary cough seen daily 
in children's work need only be referred to. It is an acute inflam- 
matory condition of the mucous membrane of the respiratory tract, 
involving most frequently the fauces, the larynx, and bronchi. 

Incipient tuberculous infiltration in any portion of the lungs or 
pleura may produce the persistent cough. Thorough physical ex- 
aminations and careful observation of all the cases for a few days 
will make a diagnosis possible. 

Pertussis without the whoop or vomiting may cause a persistent 
cough. It runs its course and subsides in from four to eight weeks. 
A diagnosis is possible only when there is a history of exposure to 
the disease. The treatment for the various conditions producing 
cough is referred to under their respective headings. 



270 DISEASES OF THE RESPIRATORY TRACT 



BRONCHITIS 

Bronchitis in children may be divided into three types : primary, 
secondary, and chronic. 

Primary bronchitis is usually the result of exposure. It occurs 
in all classes and conditions of children. In New York city it is 
a very prevalent disease during inclement weather and is indirectly 
the cause of many deaths. Rachitic and otherwise poorly nour- 
ished children are particularly predisposed to attacks. The younger 
the child, the greater the susceptibility and the more dangerous 
the affection. 

Secondary bronchitis is most often associated with measles 
whooping-cough, and bronchopneumonia, although it may be a 
complication of almost every ailment of early life. 

Chronic bronchitis is somewhat rare in young children. Ir 
is seen most frequently in asthmatics, in slow convalescence after 
bronchopneumonia, and is always present in chronic pulmonary 
tuberculosis. 

The onset of an acute attack of bronchitis is usually sudden. 
There is cough, followed by fever which is seldom high, occasionally 
touching 102° F., but almost never remaining above this point 
for any length of time. The usual temperature range is from 100° 
to 102° F., the respirations are slightly accelerated, rarely above 
thirty per minute, and there is moderate prostration. In a severe 
attack the appetite is interfered with, the child is restless, peevish, 
and shows general discomfort. Examination of the chest early 
in the attack will reveal a harsh, rough respiratory murmur, pretty 
evenly distributed all over the lungs. Sonorous, sibilant, and the 
various types of mucous rales make their appearance in from 
twelve to twenty-four hours. Among thousands of these cases 
I have never seen a single uncomplicated bronchitis with a 
temperature range above 102° F. When the temperature gets 
above this point, or higher, and remains there, there has always 
been found a complication of some sort — something other than 
the bronchitis to help account for the fever. Often this is tonsilli- 
tis, gastro-enteric disturbance, or a beginning bronchojDneumonia. 
With a temperature ranging above 102° F. and respirations of forty 
or over, we may be almost certain of a developing pneumonia. 

The duration of an attack of bronchitis is ordinarily stated to 
be from five to ten days. This is an error. The duration depends 
to a slight extent upon the child, but to a much greater degree 
upon the method of treatment. A primary case properly managed 
should be well in five days. Many cases are not treated at all by 
the physician, because he is not consulted, and some cases even 
then are not properly treated. It is these cases of neglected bron- 
chitis which furnish a great majority of our cases of bronchopneu- 



BRONCHITIS 271 

monia, a disease which contributes largely to the mortality of 
children under five years of age. 

Signs of consolidation in the lung are not necessary for the 
diagnosis of pneumonia. Cases very often reported as capillary 
bronchitis, in which there is rapid breathing — 40 to 60 a minute — 
high temperature, 103° to 105° F., and marked prostration, show 
at autopsy the pneumonic elements which gave during life no other 
signs in the chest than a diminished respiratory murmur and many 
fine mucous rales. 

Treatment. — Before indicating what should be done in a case of 
bronchitis it may be as important, by way of emphasis, to advise 
what not to do. Do not seal the room up tight by keeping all the 
vv^indows closed. Do not use an oil-silk jacket lined with wadding or 
any other material. Do not allow the child to be wrapped in blankets 
and shawls and held against a warm adult body. Do not give the 
child large doses of so-called "expectorants" — a teaspoonful of 
a heavy syrup. The temperature of the room should be kept as 
near 70° F. as possible. There should always be direct communi- 
cation with the open air. A window lowered an inch or two from 
the top, or the window-board described on page 44, is a safe means 
of assisting in ventilation. The child should be kept in its crib 
and wear the night-clothing it was accustomed to wear in health. 
Many children with bronchitis do not feel particularly ill and rebel 
against the enforced inactivity ; for such as cannot be kept under 
the covers, a pinning-blanket or a bath-robe may be worn while the 
child sits up in bed, but it should not be allowed to sleep in either. 

The Diet. — If there is little or no fever, the diet need be reduced 
but little. If there is fever, 100° to 101.5° F., with restlessness and 
irritability, the food should be reduced in strength, giving the same 
amount of fluid as in health, the reduction being made by giving 
plain boiled water frequently to drink between the feedings. The 
diet of a nursing baby can best be reduced by giving him a drink 
of water before each nursing, and shortening the time allowed for 
nursing from one-third to one-half. We will thus avoid digestive 
disturbances, which often act as a very serious complication to the 
•existing disorder. Older children, those on a mixed diet, may be 
given toast, cocoa, milk, broths, gruels, and fruit- juices. 

Steam Inhalations. — Properly administered medicated steam in- 
halations are of greater service in bronchitis, particularly in young in- 
fants, than any other measure of treatment which we possess. The 
steaming is best administered when the child is placed in its crib, which 
is covered and draped with sheets. The croup kettle (Fig. 27) with 
alcohol lamp attachment is the most convenient means for genera- 
ting steam. The nozzle of the croup kettle, which rests on a chair or 
stand, is carried under the tent at a safe distance from the child's 
hands and face. For inhalation, creosote has given better results 



272 



DISEASES OF THE RESPIRATORY TRACT 



than has any other drug. Ten drops are added to one quart of 
boihng water and the steaming continued for thirty minutes. Ordi- 
narily, in an urgent case, steaming of thirty minutes is given at 
two-and-a-half -hour intervals day and night until the child recovers. 
Older children and those in whom the condition is not grave need 
not be steamed after the bedtime of mother or nurse. It is well 
to allow a change of air in the enclosed space at least three times 
during the steaming. This is done by raising the sheet for a 
moment or two and then replacing it. 

Counter -irritation. — Counter-irritation of the skin over the 
thorax is another very useful method of treatment in bronchitis. 
Full instructions must be given the mother and nurse as to how the 
counter-irritant is to be appHed, or the application will be very indiffer- 
ently made. In my hands the mustard plaster (page 515) has been 
the most convenient means of counter-irritation, and has given the best 

results. It is well to begin with a strength 
of one part of mustard and two parts of 
flour. Two or three applications of this 
strength may be made. Later, when the 
skin becomes sensitive, the plaster is made 
weaker by the addition of more flour, one 
part of mustard to five or six of flour. 
In order to be effective the plaster should 
remain in contact with the skin from five 
to fifteen minutes, until a diffuse blush 
appears. The plaster is prepared as fol- 
lows: Mix the mustard and the flour, 
using lukewarm water until a paste of 
medium thickness is formed. This is to be 
spread on cheese-cloth, old linen, or thin 
white muslin to a thickness of about ^ of 
an inch. Over this one thickness of cheese-cloth is placed. The size of 
the plaster depends upon the age of the child and the area of lung in- 
volved. In a case of general bronchitis the entire thorax, front and 
back, should be covered. It is easier to make two plasters which meet 
under the arms than to make one to encircle the thorax, as is some- 
times done. A circle is cut out for the arms at the upper corners. 
The plasters are sufficiently large to meet at the sides, as mentioned 
above, when they may be pinned together. When all is completed, 
it really amounts to a mustard jacket. The plaster may be applied 
from two to four times daily, depending upon the urgency of the 
case. Counter-irritation thus made is of great service early in the 
attack — during the stage of acute congestion. I question whether 
plasters are of much use after two or three days have elapsed. After 
removing the plaster an application of vaselin is grateful to the 
patient. 




Fig. 27.— Croup Kettle with 
Alcohol Lamp Attachment. 



BRONCHITIS 273 

Mustard Baths. — A mustard bath (page 30), ^ ounce of mustard 
to 6 gallons of water at a temperature of 110° F., is of considerable ser- 
vice in the very acute cases in young children with extensive involve- 
ment of the fine tubes — a type of case usually known as "capillary bron- 
chitis." These cases are very apt to develop into bronchopneumonia, 
if they are not such from the beginning. There is considerable 
shock, the hands and feet are often cold, the respiration rapid, and 
the child considerably prostrated. The bath may be repeated with 
advantage at intervals of from six to eight hours. It will not be of 
value after forty-eight hours. 

Drugs. — The value of drugs in the management of this disease has 
been considerably overestimated, and they are mentioned last because 
they are the least important of the remedial measures referred to. 
During the first stage of bronchitis, that of engorgement, indicated 
by a short, dry cough, and rough, sonorous breathing on auscultation, 
small doses of castor oil and syrup of ipecac furnish us our best 
medication; from the first to the third year, two to three drops 
of castor oil and two to three drops of syrup of ipecac may be 
given every two hours; after the third yesiT, three drops of syrup 
of ipecac and five drops of castor oil every two hours. At least 
eight doses should be given in tw^enty-four hours. Ordinarily, after 
twenty-four hours, auscultation will reveal a freer secretion in the 
bronchi, the fever w^ill diminish, and the child's cough will become 
loose and less severe. The benefits from the oil and ipecac will be 
accomplished in from forty-two to seventy-two hours, when this 
medication should be discontinued. 

If the cough and the chest sounds tell us that the bronchi are 
not yet clear, a combination of tartar emetic, powdered ipecac, 
and ammonium chlorid may be used. For a child under six months 
of age a powder or tablet containing y-g-g- grain of tartar emetic, 
-g-V grain of powdered ipecac, and ^ grain of ammonium chlorid should 
be given at two-hour intervals, eight doses in twenty-four hours; 
from six months to one year, tartar emetic y^-Q grain, powdered 
ipecac i-V grain, ammonium chlorid ^ grain, at two-hour intervals, 
eight doses in twenty-four hours. If the cough is very annoying 
and severe, requiring a sedative, |- grain of Dover's powder may 
be added to each dose for children under six months and ^ grain 
for children over six months of age. From one to three years of 
age, tartar emetic y^ grain, powdered ipecac yV grain, ammonium 
chlorid ^ grain at two-hour intervals, eight doses in tw^enty-four 
hours, ^ grain of Dover's powder to be added to each dose if the char- 
acter of the cough demands it. The tablet or powder, whichever 
is employed, should be given in two teaspoonfuls of thin gruel or 
plain water. After the third year gV grain of tartar emetic, 2V 
grain of pulverized ipecac, and i grain of ammonium chlorid may be 
given ever}^ two hours, eight doses in the twenty-four hours. The 



274 DISEASES OF THE RESPIRATORY TRACT 

use of tablets or powders should be insisted upon, particularly in 
very young children. The large doses of ammonium salts and 
ipecac in heavy syrups are to be avoided because of their liability 
to produce stomach disturbance. 

The treatment of secondary bronchitis depends to a certain 
extent upon the disease with which it is associated, and the treat- 
ment should be modified accordingly. Counter-irritation and medi- 
cated steam inhalations ordinarily can be used, as they interfere but 
little with other necessary treatment. 

In chronic bronchitis the removal of enlarged tonsils and adenoids, 
fresh air, and change to a dry climate, if possible, are our best means 
of treatment. In addition, general supporting treatment is to be 
advised (see The Management of Delicate Children). Creosote 
in small doses, i to 3 minims after meals, for a child from two to 
five years of age, has seemed to me to be of service with some of 
these children. My greatest success, however, with these cases 
has been achieved by ignoring the bronchitis temporarily and put- 
ting the child in the best hygienic surroundings. Outdoor life inland 
and a nutritious diet are far better than drugs. In many of these 
cases, under such a regime, the disease for which the child was brought 
for treatment entirely disappeared without any specific medication 
whatever, showing that the bronchial catarrh w^as nothing more or 
less than a manifestation of a greatly reduced vitality. 

RECURRENT BRONCHITIS 

Recurrent bronchitis without the association of asthma is oc- 
casionally encountered. A case of this kind was seen by me five 
months ago which was so typical that I will give a brief history 
of it as taken from my records: 

Illustrative Case. — A plump, well-nourished, four-year-old girl 
was brought with a history of attacks of bronchitis lasting from 
five to seven days at intervals of not longer than three weeks. 
The physical examination was negative. The attacks com- 
menced when she was two years of age and had continued for 
two years. There never was a temperature of over 100° F. with 
the attacks and the child was not physically ill. There had never 
been cyclic vomiting, tonsillitis, or rheumatism. The father was 
a sufferer from chronic rheumatism. The patient was given a 
diet suitable for her age (page 134), meat being allowed every sec- 
ond day. She was taking considerable sugar, which was greatly 
reduced, only enough being allowed to make the food palatable. 
She was given the following prescription: 

I^. Sodii salicylatis (wintergreen) gr. xxxyj 

Sodii bicarbonatis gr. Ixxij 

Elixiris simplicis ov 

Aquae q. s. ad oij 

M. Sig. — One teaspoonful twice daily after meals. 



RECURRENT BRONCHITIS 275 

The above prescription was given for five days, followed by 
an interval of five days' rest. This procedure has now been con- 
tinued for five months, during which time there has been no bron- 
chitis. This period includes the spring and one summer month, 
but as the attacks had occurred during the previous summer as 
frequently as during the winter, the season of the year cannot be 
considered an element in the relief of the patient. As when a child 
develops joint or bone disease, the family can usually recall an 
injury or fall of some sort to account for the trouble, so also, in the 
event of bronchitis, an exposure, a change of clothing, or a change 
in the weather will usually be regarded as a cause of the attack. 

In the case above cited, and in others also, such factors evidently 
have had very little, if anything, to do with the bronchitis, for under 
the same climatic conditions the attacks have ceased when atten- 
tion was given to the constitutional condition, and proper diet and 
medication prescribed. The patients are usually of gouty or rheu- 
matic ancestry. Some of them have had growing pains, and others 
chorea. 

General Management, — The management of these cases is as fol- 
lows : The child should lead an active outdoor life when climatic con- 
ditions allow. There should always be communication between the 
sleeping- room and the outer air. Red meats, including beef, mutton, 
and lamb, are given only every second or third day. Sugar is allowed 
only in sufficient amount to make the food palatable. If the case 
resists treatment, sugar is discontinued and saccharin is substituted. 
Skimmed milk is given as a drink, eight ounces being allowed both for 
breakfast and supper. Fruits, green vegetables, and cereals well 
cooked and suitable for the age are given freely. There must be a 
free evacuation of the bowels daily. If there is a tendency to consti- 
pation, the oil treatment (page 185) is prescribed. These patients 
are not influenced by the usual treatment for bronchitis, so that 
expectorant drugs may be omitted. Large doses of bicarbonate 
of soda do more toward shortening the attack than does any other 
form of medication. For a child five years of age, five grains should 
be given at two-hour intervals. The interval treatment with diet 
must be relied upon to prevent a recurrence of the attacks. Sali- 
cylate of soda (wintergreen) is given for five days, in doses of from 
three to five grains, well diluted, after meals. The salicylate is 
then discontinued and the bicarbonate is given for five days in the 
same dosage, when the salicylate is resumed. In this way, by 
alternating the two drugs or by giving aspirin when the salicylate 
disagrees, the treatment is continued for months. As the case 
improves, an interval of rest from all medication is instituted. If 
it is more convenient, the salicylate and the bicarbonate of soda 
may be given at the same time. The skin in these cases should be 
kept active ; once daily the child should be given a tub-bath in luke- 



276 DISEASES OF THE RESPIRATORY TRACT 

warm water. After the bath, a cool spray or spinal douche is used, 
the temperature of the water ranging from 50° to 70° F. An ex- 
cessive degree of cold is not advisable; it should be sufficient, 
however, to insure good reaction after a brisk rubbing with a rough 
towel. 

BRONCHIAL ASTHMA 

By bronchial asthma in children we understand a condition 
characterized by recurrent attacks of bronchial spasm of widely 
varying degrees of intensity and duration, toxic or reflex in origin, 
associated either with an involvement of the nasopharynx or the 
bronchial mucous membrane in the form of turgescence or inflam- 
mation. I have come to divide my cases of asthmatic children 
into two classes. To the first class belong comparatively few: 
those in whom paroxysms are produced by direct irritation, as 
by the pollen of plants or the odors of animals or flowers, which 
produce what is known as "hay-fever " and the associated asth- 
matic condition. Hay-fever is rarely seen in children under five 
years of age. In by far the greater number of my patients, which 
constitute the second class, who have suffered from asthma there could 
be discovered the so-called " iithemic diathesis"; in other words, 
there was a gouty or rheumatic association. Among these, cases of 
recurrent bronchitis (page 274) and asthma are included. In not 
a few cases of recurrent bronchitis there is asthma of such a slight 
degree that it may escape observation. In others it is entirely 
absent. Repeated acute attacks of asthma give rise to pulmonary 
emphysema which emphasizes the necessity of early medical treat- 
ment. I have two patients under my care, both under ten years, 
of age, who are hopeless invalids because of marked emphysema 
due to repeated attacks of asthmatic bronchitis. Both cases were 
neglected in their early management. In the lithemic type the 
attacks sometimes occur with such regularity as to suggest the 
** explosion " seen in cyclic vomiting. Enlarged tonsils and adenoids 
may exist as accessory exciting causes. Otherwise they cannot be 
looked upon as etiologic factors. 

Illustrative Case. — A girl eight years of age was brought to 
me three years ago with the history of an attack of asthmatic 
bronchitis every month for several years. The asthma was not 
severe. It was present at the onset of the attack and lasted 
perhaps for twenty-four hours. The bronchitis usually cleared up 
in about five days. She had spent but little time in New 
York because of her so-called frequent "colds." Her mother 
brought the child to me in view of a contemplated change of resi- 
dence. In Florida and Lower California, where she had passed the 
winter, the attacks had occurred, but were mild in character. As 
soon as she returned home the attacks returned, keeping her from 



BRONCHIAL ASTHMA 277 

school for one week out of every four or five. In taking the per- 
sonal history, the matter of adenoids and tonsils was mentioned, 
when the mother hastened to inform me that the adenoids and tonsils 
had been removed twice, thus demonstrating that they were not a 
factor in the case. The child had never suffered from rheumatism. 
or cyclic vomiting. Aside from revealing a mild secondary anemia 
and slight emphysema the physical examination proved negative. 
As to her family history, I learned that all of the child's antecedents 
on both sides, for three generations, had suffered either from rheu- 
matism or gout. Her mother had been a lifelong sufferer from rheu- 
matism. Upon close questioning as to the child's diet, it was found 
that it consisted of red meat twice daily; she "hated " vegetables, 
took cereals only when "loaded " with sugar, and drank milk only 
when two teaspoonfuls of sugar were added to each glass. She 
had candy and cake ad libitum. She was recovering from an attack 
of bronchitis when I saw her, and was taking an expectorant cough- 
syrup. This was discontinued, red meat was permitted but twice 
a week, the sugar was largely reduced, saccharin being used in the 
milk to satisfy the abnormal craving for sweets. She was bribed 
by the mother to eat green vegetables and cereals. The desserts 
consisted largely of stewed fruits flavored with saccharin. Candy, 
cake, and pastry were forbidden. She was given four grains of the 
salicylate of soda (wintergreen) three times daily for five days, 
which was followed by ten grains of the bicarbonate three times daily 
for five days; then for five days there was no medication. This 
treatment was continued for six months. During the following six 
months the salicylate and the bicarbonate of soda were given but 
five days each out of each month, and during the entire year but 
one mild attack of bronchial asthma occurred. 

A most striking case of periodic asthmatic bronchitis occurred in 
a boy nine years of age. 

The father had had inflammatory rheumatism. Of the mother's 
family, the grandmother was an invalid with rheumatism. The 
grandfather was troubled sHghtly with it. 

The boy was pale, but well nourished, very active mentally. His 
weight was sixty-eight pounds. He had had chicken-pox and one 
attack of tonsillitis. The blood examination showed 78 percent of 
hemoglobin, 5,500,000 red cells, and 8000 leukocytes. The urine 
was negative. For the previous year he had a great many attacks 
of asthmatic bronchitis. The mother stated that they occurred 
once every three or four weeks. Previous to this time there had 
been very frequent colds, so many that the boy's attendance at school 
had been practically nil. The mother had discovered that sugar 
did not agree and very little had been given. He was very fond of 
red meat, however, and wanted it three times a day. He was given 
it twice a day. 



278 DISEASES OF THE RESPIRATORY TRACT 

A diet of green vegetables, fruits, and milk cereals was ordered 
to be given freely. In addition, eggs or bacon was to be given for 
breakfast. Red meat to be given three times a week, poultry three 
times a week, and fish once a week. Sugar was excluded absolutely, 
saccharine being used. Asparin in two-grain doses was given after 
each meal with five grains of bicarbonate of soda. 

This was the treatment for three months, during which term there 
was one attack of the asthmatic bronchitis. This responded to 
ipecac, antipyrin, and soda bromid. Other than one or two slight 
colds, the boy has experienced no trouble during the past winter. He 
has lost but little time at school. At the end of seven months he had 
gained seven pounds in weight. 

The bicarbonate and asparin were given continuously for three 
months. Since then they have been given alternately, each for 
five days — i. e., two grains of asparin three times daily for five 
days, then five grains of bicarbonate of soda twice daily for five 
days. 

Treatment. — The management of bronchial asthma consists of 
care during the attack, and the interval treatment, the latter being 
by far the more important. In infants and young " runabouts " with 
this type of trouble, there is usually considerable bronchitis, and this 
requires our attention. I have found, in addition to the usual 
laxatives, calomel or castor oil, that a combination of syrup of 
ipecac, antipyrin, and bromid of soda gives the most prompt results 
as far as internal medication is concerned. For a child six months 
of age the following prescription has been found useful : 

I^. Syrupi ipecacuanhae gtt. xviij 

Antipyrinai gr. vj 

Sodii bromidi gr. xviij 

Syrupi rubi idaei 5 v 

Aquae q. s. ad§ij 

M. Sig. — One dram every two hours — six doses in twenty-four hours. 

Vox one year of age: 

I^. Syrupi ipecacuanhae gtt. xxiv 

Antipyrinae gr. xij 

Sodii bromidi gr. xxiv 

Syrupi rubi idsei 5 v 

Aquae q. s. ad 5ij 

M. Sig. — One teaspoonful at two-hour intervals — six doses in twenty- 
four hours. 

For a child from two to three years of age : 

I^. Syrupi ipecacuanhae gtt. xxxvj 

Antipyrinae gr. xviij 

Sodii bromidi gr. xxxvj 

Syrupi rubi idaei 5 v 

Aquae q. s. ad §ij 

M. Sig. — One teaspoonful in water at two-hour intervals — six doses in 
twenty-four hours. 



BRONCHIAL ASTHMA 279 

In addition to the internal medication, the child will often be 
greatly relieved by stimulant inhalations as described under Spas- 
modic Croup (page 262). If the condition is urgent, the inhalations 
may be given for thirty minutes with thirty minutes' rest. Mus- 
tard in the proportion of one part of mustard to two parts of flour 
(page 272), so applied as to envelop the entire thorax, will often 
relieve the spasm sufficiently to reduce the respirations from ten 
to twenty a minute. The mustard should remain on long enough 
to redden the skin and should not be repeated oftener than once 
in four hours. The cold-air treatment in bronchial asthma is con- 
traindicated, regardless of the age of the patient. Warm moist 
air at from 68° F. to 70° F. is best. A sudden blast of cold air may 
be sufficient to increase the severity of the paroxysms to a marked 
degree. Ventilation, however, is a necessity in these cases. The 
best means of obtaining it is by the use of two rooms, one of which 
may be aired while the other is occupied. Before the child is changed 
to the aired room, its temperature should be raised to that of the 
other. 

In older children after the fifth year the bronchial spasm may 
be considerable, and more active measures may be required to fur- 
nish temporary relief. Here the methods usually employed for 
the same purpose in adults may be brought into use. A few whiffs 
of chloroform will often be effective. Fumes of nitrate of potash 
paper will sometimes be of service. At this age, also, a combination 
of antipyrin and bromid of soda may be brought into use. For a child 
from five to ten years of age, three grains of antipyrin with from 
six to ten grains of bromid of soda, repeated in two hours, will often 
be followed by a cessation of the paroxysm. As soon as the spasm 
subsides the sedatives should be discontinued. I have never found 
it necessary to give morphin hypodermatically or otherwise in these 
cases. In a very severe case, in a girl eight years of age, a com- 
bination of antipyrin and codein in full dosage was required to 
control the paroxysms. She was given one-fourth grain of codein 
and four grains of antipyrin at two-hour intervals until three doses 
had been given. 

The interval treatment for the bottle-fed consists in a reduction 
of the sugar to one-half the amount suitable for the age and the 
use of one grain of bicarbonate of soda for each ounce of the milk 
food given. The bowels must be kept properly open, although 
constipation or intestinal toxemia has never appeared to me to be 
an important factor in asthmatic children. The interval treat- 
ment for older children is most important, for by it we are able to 
postpone the attacks. These cases, as I have indicated, are usually 
in lithemic subjects, and the scheme of management followed out 
is the same as for rheumatism, chorea, recurrent bronchitis, and 
cyclic vomiting. Sugar is reduced to a minimum, red meat is given 



28o DISKASES OF THK RE^SPIRATORY TRACT 

not oftener than every second day, and then only in moderate 
amounts. The child's proteid nutrition is maintained by the use 
of a high-proteid cereal, such as oatmeal, and purees of dried peas, 
beans, and lentils. The eating of green vegetables is encouraged. 
Food between meals is forbidden. Fruits are used in moderation 
and an active outdoor life is encouraged. At bedtime the child 
is given a brine bath (page 31), followed by a vigorous dry rub. 
The mother or attendant is instructed that one bowel evacuation 
daily must be insured. The medication consists of bicarbonate 
of soda, from five to ten grains a day for five days, alternating 
with the salicylate of soda (winter green) in doses of from three to 
five grains three times a day. This is continued for a month or 
two until its effect on a recurrence is noted. If the salicylate of 
soda disturbs the digestion, the same quantity of aspirin may be 
given. The further continuation of the medication depends upon 
the effect produced. Usually in two months the salicylate may 
be given in smaller doses. Interrupted medication, however, should 
be continued for several months. When my cases with a bad family 
history have been relieved, I continue the diet permanently, giving 
the medication for but five or ten days and then omitting it for 
sixty or eighty days, when it is again given for a short time, con- 
tinuing thus for as long as may be thought best in the individual 
case. 

BRONCHOPNEUMONIA; CATARRHAL PNEUMONIA 
Catarrhal pneumonia, on account of its large mortality, and 
because of its frequent appearance as a complication of almost 
every disease of infancy, is one of the most formidable ailments 
which we are called upon to treat. The disease is usually described 
as primary or secondary. Among the several hundred cases which 
have come under my observation comparatively few — less than 
5 percent — were primary. Those described as primary usually 
follow a bronchitis, often a neglected bronchitis. The disease 
varies considerably as regards its severity, depending on the age 
and condition of the child, the nature of the infection, and the amount 
of lung involved. It is most fatal when associated with diphtheria 
or measles. 

Catarrhal pneumonia demands our most careful attention, 
not only on account of the deUcate organs attacked, enclosed in 
weak thoracic walls, but because — unlike lobar pneumonia, scarlet 
fever, typhoid fever, and many other diseases of early life — it has 
no self -limitation, no cycle. While in the other diseases mentioned 
we are required only to assist a patient through the various stages, 
in catarrhal pneumonia we must do more, for here a cure is demanded. 
Treatment. — Every child at the commencement of an illness has a 
definite resistance to it. In catarrhal pneumonia, for the reasons just 



i 



bronchopneumonia; catarrhal pneumonia 281 

given, it must be our effort to preserve every strength unit which 
the child possesses. An immense amount of vitaUty is wasted in sick 
children because of irritability, restlessness, and loss of sleep. One 
of the first duties in a given case is not to give this or that drug, 
or use this or that local application, but to make the child com- 
fortable — to put him in the best position to withstand disease. 
We must establish a sick-room regime which will make this possible. 

The Sick-room. — The value of a constant supply of fresh air is 
too little appreciated. In every case there should be a direct com- 
munication between the sick-room and the open air, throughout the 
attack. Various means of ventilation have been devised, of which 
the window-board (page 44) is the most effective, as it separates 
the sash and allows the free entrance of a current of air which is 
directed upward. If plenty of fresh air at a proper temperature 
were available during the early part of the illness, there would be 
much less use for tanks of oxygen later. 

An absolute necessity in a sick-room is a good thermometer. 
In pneumonia cases it should never register above 70° F. There 
is marked tendency to coddle, to wrap, to overdo the, pneumonia 
patients. The patient requires, even during the winter, absolutely 
nothing more than a medium- weight flannel shirt, a band, if one 
is ordinarily worn, and the usual night-dress. Some years since I 
discarded the oiled silk jacket. It is cumbersome, it is impossible 
to keep clean, and it overheats the patient. Given an infant with 
catarrhal pneumonia, have him heavily clad, keep him in an un ven- 
tilated, overheated room, in close contact with an adult body, and 
you have a patient who is tremendously handicapped. There is 
but one place for a sick infant, and that is in his own roomy crib. 

Diet. — In every illness with fever, the digestive capacity is con- 
siderably reduced. If the usual milk diet is continued, we are very 
liable to have a gastro-enteric infection added, oftentimes as a serious 
complication, to the existing disease. In the breast-fed a drink 
of water is ordered for the child before the nursings and between 
them. The nursing hours should be the same as in health, but the 
time allowed for each nursing should be reduced from one-third to 
one-half. In the bottle-fed the milk strength should be reduced 
from one-third to one-half by dilution with water, the quantity re- 
maining the same. Children from two to four years of age are put 
on a diet of diluted milk, gruels, and broths. 

Bowels. — Normal bowel function is more necessary for the sick 
than for the well. There should be at least one stool in twenty-four 
hours. 

General Treatment. — Having placed the child under the best 
dietetic and hygienic conditions, we are in a position to use medi- 
cation to a much better advantage. But in its use, and in perform- 
ing the various offices for the patient, it must be our effort to disturb 



282 DISEASES OF THE RESPIRATORY TRACT 

him as little as possible. In our anxiety to do, we are very liable to 
overdo, with disastrous results. If a well child were given syrup ex- 
pectorants, stimulants, baths, and local applications, something being 
done for him every hour or two in the twenty-four, he would have 
to be a strong child to withstand the treatment. We should treat 
our ill with still greater consideration. Make the intervals between 
which the child is to be disturbed at night as long as possible b)- 
giving food, medicine, and local treatment at one time. When 
possible, I always endeavor to make the interval at least three hours. 

Steam Inhalations. — Among the distinctly remedial measures, 
aside from those administered internally, steam inhalations with creo- 
sote deserve an important place. The patient is placed in its crib, 
which is covered and draped with sheets so as to make a fairly tight 
enclosed space. The apparatus necessary is an ordinary croup kettle 
(see page 261). Ten drops of creosote are added to one quart of 
water and placed in the kettle. The nozzle of the kettle is intro- 
duced between the sheets at a safe distance from the child's face 
and hands, the steaming being carried on for thirty minutes every 
three hours. The sheets should be parted slightly about every ten 
minutes, to allow a renewal of the air. The inhalations are to be 
given whether the patient is sleeping or waking. As he improves, 
they may be given less frequently until normal respirations and the 
chest signs tell us they are no longer required. 

Counter-irritants . — The application of counter-irritants to the skin 
over the thorax is, to my mind, of great service in cases in which there 
is much bronchial catarrh, which includes, of course, most cases. In 
order that a counter-irritant may be of service, a distinct red blush 
must be produced on the skin. Turpentine diluted with oil, — one- 
third turpentine and two-thirds oil, — when briskly rubbed on the parts 
for a few minutes, produces a fairly satisfactory counter-irritation. 
The old-fashioned home-made mustard plaster has served me well 
as a counter-irritant. Written directions should always be given 
for the preparation of the plaster, and the boundaries of the area of 
the skin to be covered should be outlined with a pencil on the 
skin's surface. If the nurse or mother is told merely to put a mus- 
tard plaster on the chest, a plaster the size of a man's hand will 
usually be placed somewhere between the umbilicus and the chin! 
For the first two or three applications one part of mustard to two 
parts of flour is used. This is moistened with hot water and made 
of the consistency of a rather thin paste, which is then spread upon 
cheese-cloth, old muslin, or linen, cut to the desired size. The plas- 
ter is readily held in position by a bandage of any thin material 
extending around the chest. When the skin is well reddened, 
usually within from five to fifteen minutes, the plaster is removed 
and vaselin or sweet oil applied. I never use a plaster oftener 
than once in six hours, and then only in the severest cases. Ordi- 



( 



bronchopneumonia; catarrh al pneumonia 283 

narily, two or three applications in twenty-four hours are sufficient. 
If the plasters are continued for several days, in order to avoid 
blistering, it will be necessary to make them much weaker after a 
day or two — one part of mustard to five or ten of flour. Counter- 
irritation is particularly effective when used at the commencement 
of an attack. 

Mustard Baths. — In cases of sudden onset, with high fever, rapid 
breathing, and cold extremities, a mustard bath — one tablespoonful 
of mustard to six gallons of water at 110° F. — will often furnish 
marked relief to the immediate symptoms. Autopsies on these cases 
show a general congestion of the internal organs, with intense con- 
gestion of the lungs. The bath may be repeated at six-hour inter- 
vals. This type of case is usually very rapid in its development, the 
child being relieved or dead in from thirty-six to forty-eight hours. 
By "relieved "we do not mean that the child has recovered, but 
that the acute urgent symptoms have subsided. In my opinion 
only these cases should be considered primary. 

Drugs. — The internal medication is, to a large extent, sympto- 
matic. In any disease a great deal of harm may be done to young 
children by the thoughtless use of drugs. In catarrhal pneumonia it 
is particularly necessary that, in our endeavors to assist the patient, 
we do nothing to harm him, for we are treating a disease in which 
his powers of resistance count for everything. In young children, 
even in health, the digestive functions are very easily disordered. 
In illness with fever, with the accompanying nervous exhaustion, 
the stomach is most easily disturbed, the child is not properly nour- 
ished, and his powers of resistance are markedly diminished. 

Expectorants must be given with care and are better prescribed 
in the form of tablets or powders. The use of heavy syrups of 
wild cherry, tolu, etc., with large doses of the ammonium salts, 
only adds to the burden of the patient. For a child one year 
of age with catarrhal pneumonia, y^o^ grain of tartar emetic and 
4V grain of ipecac answer well as an expectorant. If the cough is 
very severe and persistent, \ grain of Dover's powder in tablet form 
with sugar of milk dissolved in at least two teaspoonfuls of water, 
may be given, preferably after feeding, not oftener than once in 
two hours. The ammonium salts so generally used in catarrhal 
pneumonia as routine treatment are badly borne by the stomach. 
The muriate of ammonia is of some value during resolution, but 
to a child two years old it should not be given in larger doses than 
^ grain well diluted, at two-hour intervals; personally, however, 
I rarely use it. With high fever and great restlessness, which are 
not affected by sponging, and where for any reason rational bath- 
ing is impossible, a combination of caffein, Dover's powder, and 
phenacetin may be used. For a child one year of age I would give 
^ grain of caffein, ^ grain of Dover's powder, and i^ grains of phen- 



284 DISK ASKS OF THK RKSPIRATORY TRACT 

acetin at about four-hour intervals. In giving Dover's powder it 
is well to watch the bowels, as constipation often follows its use. 

Heart stimulants are usually necessary, and in their selection 
two points are to be considered — their effect on the heart and their 
effect on the stomach. But, first, what are the indications for the 
use of a heart stimulant? Ordinarily, I think, they are used too 
early. A heart stimulant should never be given simply because 
a child has pneumonia or diphtheria or scarlet fever, but it should 
be given in pneumonia or diphtheria or scarlet fever as soon as 
the heart needs assistance. And, briefly, there are two conditions 
to guide us, a very rapid pulse or a soft, usually not rapid, pulse 
with a tendency to irregularity. In a general way, I believe that a 
heart which is beating at the rate of 1 50 a minute during quiet or sleep, 
and which is not strengthened by sponging or packs, needs assistance, 
and the drug which has served me best is tincture of strophanthus, 
which acts as a direct stimulant to the heart muscle. The pulse, 
by its use, is made stronger, fuller, and less rapid. When the heart's 
action shows a tendency to irregularity, with a soft, easily com- 
pressible pulse, then strychnin is the remedy. For a child one 
year of age one drop of strophanthus in water may be given every 
three hours, or -^^-q grain of strychnin every three hours, to be in- 
creased to ■ji'o or even to y^o^ grain every three hours for a few 
doses if the case is carefully watched for symptoms of strychnin 
poisoning. Strophanthus and strychnin possess advantages over 
all other stimulants in that they do their work and have no un- 
pleasant effect on the stomach, as is the case with alcohol, digitalis, 
and the ammonium preparations. If the condition is very urgent, 
strophanthus and strychnin may be used in combination. Digi- 
talis I rarely employ because of its tendency to interfere with diges- 
tion. Alcohol in the form of whisky or brandy is very rarely of 
great service in catarrhal pneumonia. It may stimulate the heart, 
but its prolonged use greatly upsets the stomach. It should be 
withheld until late in the disease, when other means of stimulation 
fail. Then, given in large amounts, it may be the means of saving 
the patient. One-half dram of whisky or brandy, well diluted, 
may be given every hour or every two hours to a child one year 
of age. However, the cases of catarrhal pneumonia actually saved 
by the use of alcohol are few indeed. One three-hundredth grain of 
nitroglycerin every three hours for a child one year of age is of service 
in cases where there is marked cyanosis with cold extremities. Its 
use should be discontinued as soon as improvement in this respect 
is noticed. The one unpleasant effect that I have observed from 
its administration is its tendency to produce headache and marked 
restlessness. 

Baths. — A sponge-bath at 95° F. for cleansing purposes may be 
given daily. 



bronchopneumonia; catarrhal pneumonia 285 

What is to be our guide in dealing with the temperature ? At 
what degree of temperature are we to interfere, the rectal temper- 
ature alone being considered? This depends to a great extent 
upon what is behind the fever and the effect of the fever upon the 
individual patient. If a child has a high fever and is more com- 
fortable when it is reduced, — if he will digest his food better and 
sleep better, — it is our duty to reduce it. Further, by reducing 
the temperature we lessen the work of the heart, saving it often- 
times many beats a minute. Usually when the temperature has 
a tendency to run above 104° F., interference is of advantage, and 
the best means at our command is the use of local applications of 
water in the form of sponge-baths or packs. If the temperature 
is easily controlled, a sponge-bath will answer our purpose. Either 
salt or alcohol may be added to the water. Ordinarily two teaspoon- 
fuls of salt to a quart of water, or one part alcohol to three parts 
water, is ample. Cold water thus used serves two purposes — it 
acts as a sedative and it reduces the fever. Cold sponging, while 
not controlling the fever as effectually as does a bath or a pack, 
possesses the advantage that the most unskilled can use it. For 
sponging, the child should be stripped and covered with a flannel 
blanket, the sponging being done under the blanket. In order 
not to antagonize or frighten the child, it is best to begin with the 
water at 95° F. and gradually to reduce it to 70° or 75° F. by the 
addition of ice or cold water. The sponging may be continued from 
ten to twenty minutes, and should not be repeated at shorter intervals 
than ninety minutes. After the sponging is completed the skin 
should be rubbed briskly for a few minutes with a dry towel. If 
the temperature is not readily controlled in this way, it is best to 
use other means, as too frequent sponging exhausts the patient. 
As a means of controlling the temperature in children, the tub-bath 
has not been successful in my hands, for the reason that I have not 
been able by this means to control the fever. The exposure, the 
flight, and the necessary shortness of the bath render it very unsatis- 
factory. 

Cold Pack. — By far the best means at our command for controlling 
a continued high fever is by the use of the cold pack (page 503). 
Properly applied, it is without the slightest danger. It is prepared 
as follows : A large bath-towel or any thick absorbent material may 
be used, slits being cut in one end of the towel through which the 
arms may pass. The towel is folded over the body, and should extend 
from the neck to the middle of the thighs ; the arms and the legs from 
the knees down should remain free; a hot- water bag, carefully 
guarded, should be placed at the feet. The towel is moistened with 
water at 95° F. It is well to make the pack warm at first, so that the 
child will not be frightened, as shock will thus be avoided. I have 
known severe shock to follow in a case where a child with a tempera- 



286 DISEASKS OF THE RESPIRATORY TRACT 

ture of 105° F. was put suddenly into a pack at 70° F. In two or three 
minutes the towel is moistened with water at 85° F., then at 80° F. 
When 80"^ F. is reached, it is best not to make the water any colder 
for half an hour, at which time the temperature of the patient is 
taken. If, in the beginning, it was 105° F. and then shows a slight 
or no reduction, the temperature of the pack may be reduced to> 
70° or even to 60° F. by the addition of cold water or ice, without re- 
moving the child, who is turned from side to side so that all 
parts of the enveloping towel may be moistened with the cool water. 
During the first hours in the pack, the temperature should be taken 
every half hour, and when it is reduced to 102° F., the child is removed 
and wrapped in a warm blanket. In cases of sudden and persistent 
high fever, the child may be kept in the pack continuously. We 
aim to keep the temperature between 102.5° a-^d 103.5° F. The 
degree of cold necessary to control the fever in a given case will soon 
be learned. I recently kept in a pack for seventy-two hours a four- 
year-old boy, ill with lobar pneumonia. In this case a pack at 70° F. 
was necessary to keep the temperature at 104° F. or slightly lower. 
A fresh towel should be applied every three hours. An ice-bag 
should be kept at the head, a hot- water bag at the feet, and the 
patient covered with a flannel blanket of medium weight. 

Oxygen. — Oxygen is of immense service in very severe cases with 
much lung involvement. It may be given continuously for one or 
two minutes out of every seven or ten. As often given, one or two 
minutes every half hour, it is of little or no service. 

LOBAR PNEUMONIA 
The onset of lobar pneumonia is usually sudden. In about 
3 percent of the cases it is ushered in by a convulsion. In older 
children, those past the third year, there may be an initial chill. 
There is almost always high fever from the beginning of the attack. 
The face is flushed, the lips are separated and parched, and the 
child usually breathes through its mouth. The respiration is markedly 
accelerated, — forty to sixty per minute, — the end of each inspira- 
tion being marked by a peculiar sigh or groan. At this time there 
may be in the chest no discernible signs of the disease. The respir- 
atory murmur over the entire thorax is rendered harsher than nor- 
mal, but this is caused by the rapid respiration. Bronchial breath- 
ing and bronchial voice may be delayed until the fourth or fifth 
day, although they are usually present within forty-eight hours 
from the onset of the acute symptoms. In a case seen recently, 
signs of consolidation did not appear until the seventh day of the 
disease, and on that day the crisis occurred. It was objectively 
a typical case of lobar pneumonia, but without chest signs until 
the seventh day. A case of this type is usually referred to as a 
"central " pneumonia; the consolidated area being deep in the 



LOBAR PNEUMONIA 287 

lung tissue, and covered by normal lung, cannot be made out. 
The temperature at the onset will usually be from 103° to 105° F. 
In an average case the temperature range throughout an attack 
is from 103° to 105° F. 

Lobar pneumonia is a distinctly infectious disease terminating, 
in recovery cases, by crisis. The crisis may be looked for any time 
after the third day of the disease, though it seldom occurs before 
the fifth day, the usual time being from the fifth to the ninth 
day of the disease. A crisis delayed beyond the ninth day means 
a very serious infection and a very grave prognosis. I have had 
recovery cases in which the crisis did not occur until the eleventh 
day, one on the thirteenth, and one on the fifteenth day. In eight 
fatal cases in the New York Infant Asylum, two died on the eighth 
day, two on the ninth, two on the twelfth, one on the twenty-first, 
and one on the twenty-fourth day of the disease. 

Among the out-patient poor, lobar pneumonia frequently runs 
its course unrecognized. At the outdoor service of the Babies' 
Hospital we not infrequently have cases brought to us with lobar 
pneumonia in the stage of resolution. The child had a hacking 
cough with fever, and was supposed to be suffering from a cold or 
an attack of influenza. There was evidently no pain, hence nothing 
was suspected. In children localized pain in the chest is often 
absent throughout the entire attack. 

Lobar pneumonia runs a limited course, with a strong tendency 
to recovery. It is a disease which children bear well, under proper 
management — a disease for which there is no specific treatment, 
and our efforts in restoring the patient to health are supportive 
only, so that the patient may be enabled successfully to withstand 
the disease. 

Treatment. — When a child is stricken with lobar pneumonia we 
know that his physical strength is to be severely tested, and our 
first effort should be to place him in such a position that he may 
to the best advantage cope with the enemy. In order to do this, 
every detail of his daily life should so be arranged as to place all 
the organs of the body in the most favorable position to meet the 
changed conditions produced by disease. Telling the mother what 
to do for the fever and writing a prescription for a cough mixture 
is a most careless way of treating pneumonia; it is the method 
of the prescribing apothecary; physicians never do it. A proper 
regime must be established as soon as the child becomes ill. The 
bowel function, the room-temperature, ventilation, and sleep, as 
well as special medication, are to be considered. The child must 
be kept as comfortable as the conditions allow, and his comfort 
means the avoidance of everything causing restlessness or irri- 
tability, which throws more work upon the heart and diminishes 
his resistance to the disease. 



288 DISEASES OF THE RESPIRATORY TRACT 

The Sick-room. — Being usually a winter disease, the temperature 
of the room and the ventilation demand special attention. The tem- 
perature of the room should be kept at 70° F., or very near that figure, 
both day and night. Wide fluctuations in the temperature should 
not be allowed. A child with lobar pneumonia needs the best air 
that can be furnished. A large room, if at hand, should always be 
selected, and there must always be a direct communication with 
the open air. A window-board (page 44) is a convenient means 
of ventilation. The child should be kept in its crib, and not held 
on the lap of the mother or nurse. 

Quiet should be maintained in the sick-room, only those in 
attendance upon the patient being allowed there. A sick-room is no 
place for visitors and otherwise curious persons. Their presence 
annoys the child and takes away just so many strength units, which 
may determine the question of life or death. 

The Clothing. — The clothing should be the usual night-clothing. 
I have long since discarded the oiled-silk jacket or any special means 
of covering. The oiled-silk jacket or a jacket made of cotton wad- 
ding is very easy to put on, but very difficult to take off with safety; 
further, it has a tendency to elevate the temperature of the patient, 
it makes him uncomfortable, particularly during convalescence, 
and prevents the free action of the skin. These objections, with 
the fact that there is no rational argument for its use, are sufficient 
to condemn it. 

The Bowels. — The patient's bowels should move once or twice 
daily. There should be a standing order with the nurse or mother 
for an enema to be given if the bowels do not move once in twenty- 
four hours. One-half to one grain of calomel in doses of one-sixth 
of a grain every hour is usually of considerable service. In a case 
in which there is very high fever I often order the dose repeated 
every three or four days. 

Counter-irritation. — Counter-irritation of the skin is of but little 
service in lobar pneumonia. Early in the attack, when there is pain, 
a mustard plaster, — one-third mustard and two-thirds flour, — mixed 
to a paste, spread on cheese-cloth, and placed over the involved area 
will give signal relief. It may be repeated at intervals of from four 
to five hours. This form of counter-irritation is also useful in 
convalescence in delicate children when the lung clears slowly. 
The examination of these cases usually reveals feeble breathing 
and many mucous rales. In such cases two or three applications 
daily until the lung clears will answer. The application should be 
kept on until the skin is well reddened. If this does not take place 
in ten minutes, the mixture of mustard and flour should be made 
stronger — one-half mustard to one-half flour. In a few cases with 
delayed resolution, two dry cups daily, applied directly over the in- 
volved areas, have been of much service. 



LOBAR PNEUMONIA 289 

The Diet. — See Diet in Illness, page 139. 

Antipyretics. — ^Whether or not antipyretic measures are to be used, 
and the nature of the antipyretic to be advised, depends upon the case 
and the family possibilities as to care and nursing. One child will bear 
a temperature without inconvenience which would seriously compro- 
mise the chances of recovery of another, so that the thermometer is 
not the only guide. The effect of the fever upon the patient must 
guide us. Some children will be delirious and restless at 103° F. 
and will need antipyretic treatment. A temperature of 104° F. 
rarely needs interference. A rise of one degree F. will usually mean 
an increase of twenty to thirty heart-beats per minute. In lobar 
pneumonia, I prefer that the temperature should not go above 
105° F., even if at the time the child shows but little inconvenience. 
Such a temperature means an unnecessary increase in the amount 
of work required of the heart, which instead demands relief in such 
an emergency. 

Cold water, when it can be intelligently applied, is the best 
means of reducing fever. It may be used either in the form of a 
sponge-bath or a cool pack. The sponge-bath (page 30) answers 
in a few cases in which the temperature is readily influenced. It 
may be repeated at intervals of from two to four hours. As a rule, 
the cool pack (page 503) will be required, especially if the fever 
is particularly high. The sponge-bath, while not controlling the 
fever as well as does the pack, possesses the advantage that the 
most ignorant can safely use it. It really amounts to nothing more 
than sponging the entire body with cool water or alcohol and water. 
The cool pack requires a trained nurse or a very intelligent mother, 
either of whom should be instructed by the physician as to its use. 
When properly applied, and when the packs or baths agree, prompt 
improvement in the immediate symptoms follows their use; the 
child, previously restless, and perhaps delirious, falls into a quiet 
sleep. The temperature falls two or three degrees, the pulse becomes 
slower and fuller, the respiration less frequent, and when properly 
given, I have never seen a pack or bath do harm to a child. In 
fact, they are most grateful to the patients, who, when old enough, 
have asked to have the towel made cooler when it became warm 
and dry from the heat of the body. 

Heart Stimulants . — A child must never be given a heart stimulant 
simply because he has pneumonia. Heart stimulation is usually em- 
ployed too early in the attack. When the pulse shows signs of 
weakness, whether by its rapidity, its irregularity, or its reduced 
volume, then it is time for stimulants. For a very rapid pulse, i. e., 
over one hundred and fifty, tincture of strophanthus has answered bet- 
ter in my hands than any other means of stimulation. For a child 
from six months to one year old, I order one drop every two hours — at 
least six doses in twenty-four hours ; for a child from one to three 
19 



290 DISEASES OF THE RESPIRATORY TRACT 

years old, one or two drops at intervals of two hours — at least six 
doses in twenty-four hours; for a child of three years or over, two 
or three drops at intervals of two hours — at least six doses in twenty- 
four hours. If the case is a very serious one, the strophanthus 
may be given every two hours during the entire twenty-four; but, 
if the conditions permit, it is better to disturb the patient as in- 
frequently as possible during the night. 

When the pulse is irregular and intermittent, with reduced 
volume, then strychnin is the remedy. For a child from six months 
to a year old, -j^q- grain *is to be given every three hours — six doses 
in twenty-four hours; from the first to the second year, -^^-g- grain 
at three-hour intervals — six doses in twenty-four hours; after the 
second year, yf"o grain may be given at intervals of three or four 
hours — six doses in twenty-four hours. Children who are -under 
strychnin medication should be carefully watched for signs of the 
physiologic effects of the drug ; the first symptoms being an unusual 
susceptibility to sudden noise and a slight fibrillary twitching of 
the muscles of the face and the backs of the hands. Instructions 
should be given, when these symptoms appear, to discontinue 
the drug until the next visit of the physician. I have repeatedly 
noticed these signs of the physiologic effects of the administration 
of strychnin, and they need cause no anxiety; in fact, they are 
necessary in order to get the full benefit of the drug. However, 
it is only in the most severe cases that the drug should be pushed 
to such an extent. 

When the circulation of the skin is deficient, with cold extremi- 
ties and cyanosis, indicated by blueness of the finger-nails and 
lips, nitroglycerin is indicated. For a child under one year of age, 
s^^o" gi'a^iii rn^^y t)e given at intervals of two or three hours — six 
doses in twenty-four hours ; for a child from one to three years of age, 
2"^ grain at three-hour intervals — six doses in twenty-four hours; 
after the third year y^-Q grain at intervals of two or three hours — six 
doses in twenty-four hours. Nitroglycerin, if given in large doses, 
produces headache, of which older children will complain, and 
nurslings will show their discomfort by restlessness and crying. 

Digitalis is rarely used as a heart stimulant in young children. 
It disturbs the stomach and the remedies mentioned above meet 
the conditions much better. The ammonium preparations are 
not employed because their administration even for a short period 
invariably interferes with nutrition by diminishing the digestive 
capacity. 

Camphor and musk, recommended by some, have a very tran- 
sient stimulating effect, and in my hands have been ineffective. 

Alcohol is often prescribed too early in pneumonia in children. 
Many of my cases of pneumonia pass through an entire attack 
without one drop of alcohol. Alcohol in any form should be avoided 



I 



LOBAR PNEUMONIA 29I 

early in the disease. Later, when the case is doing badly, when the 
strychnin and strophanthus, alone or in combination, fail, then 
alcohol may be given, and then it may be a life-saving measure. 
It is indicated at this time because it sustains the patient when 
regular food assimilation is impossible, and at the same time it 
stimulates the heart. Under one year of age I give from eight 
to thirty drops of brandy, at two-hour inter\^als; from one to two 
years of age, fifteen drops to one dram at two-hour intervals; over 
two years, one to two drams at tw^o-hour inten-^als. Cases which 
show profound sepsis will require and consume an enormous quan- 
tity of alcohol without showing the slightest intoxicating effect. 
When resident physician of the New York Infant Asylum, a child 
fourteen months of age ill with diphtheria was given four ounces 
of brandy in twenty-four hours without showing signs of stupor 
or intoxication. 

Hypodermic Stimulation. — The use of hypodermic stimulation in 
children is to be advised only in an emergency, or when the stomach 
becomes intolerant. If the dietetic means suggested are carried out, 
and if disturbing drugs such as the ammonium salts, heavy syrups, 
etc., are omitted, there will rarely be any occasion to resort to hypo- 
dermic stimulation. But when indicated the doses suggested for 
the stomach may be given hypodermically, with the exception of 
alcohol, which should not thus be given in quantities greater than 
one-half dram of brandy or whisky at one time. 

Gavage. — Cases will be encountered in which, on account of the 
profound toxemia, no food or medicine will be taken. Here the 
giving of stimulants and predigested food by means of gavage (page 
140) will be of material assistance. The milk used should be com- 
pletely peptonized, and to it whisky, brandy, and stimulating drugs 
may be added. The forced feeding should not be used oftener than 
once in four hours, usually once in six hours is preferable. AVhen 
thus given the amount of the stimulants should be increased. 

Colon flushing (page 518) with a normal salt solution, at iio° 
F., is of great service in pneumonia when there is extreme pros- 
tration. A pint or more of the solution may be used alone or com- 
bined with one-half dram of brandy or whisky. The fluid should be 
carried high up into the descending colon. As the rectum soon 
becomes intolerant, the flushing should not be repeated oftener than 
once in six or eight hours. 

Specific Medication. — There is no drug known which will cut 
short or abort an attack of lobar pneumonia. Mercury in the 
form of large doses of calomel, quinin, salicylate of soda, and other 
drugs have no speciflc action. As previous^ stated, our efforts 
must be directed toward a conservation of the strength of the patient 
by placing him in the best position to cope with the disease. This, 
with careful medication to meet special requirements as they arise. 



292 DISEASES OF THE RESPIRATORY TRACT 

constitutes our treatment of lobar pneumonia, and has given us 
a death-rate of only 2 percent in children under two years of age. 
During convalescence great care is needed as to permitting the child 
to resume his usual habits of life, for in these matters, as well as 
in regard to food and exercise, we must make haste slowly. 

PRIMARY PLEURISY 

Acute primary non-rheumatic pleurisy is a very rare condition 
in children. I have seen but four cases under nine years of age — one 
was eight, one seven, and one four years of age, and one only fif- 
teen months old. 

Its onset is practically the same as in adults. There is localized 
pain, the so-called "stitch in the side," the respiration is rapid, 
forty to sixty to the minute, and shallow; the skin is dry and hot; 
the cough is teasing, and, on account of the pain which it causes, 
is partially suppressed by the patient. Fever is present which is 
usually quite high, 102° to 105° F. The pulse is rapid, one hun- 
dred and twenty to one hundred and fifty to the minute. In only 
one of my cases was the pleuritic inflammation followed by effu- 
sion. This was in the child fifteen months old. The fluid in this 
case was sterile. So far as* we could learn there was no rheumatic 
association in any of the cases. 

Treatment. — The treatment which proved successful in the four 
cases was rest in bed. The patients were given a reduced diet of milk, 
broths, and gruel. The fever was not of a very persistent character 
and was readily controlled by sponge-baths (page 30). For the relief 
of the pain, a flaxseed and mustard poultice, — one part of mus- 
tard to nine parts of flaxseed, — applied as hot as could be borne 
by the back of the nurse's hand, and changed every half hour, gave 
much relief during the acute stage. After the first twenty-four 
hours, however, poultices are of little value. Strapping the affected 
side with strips of Z. O. plaster will give much comfort where the 
pain continues after the second day. Tincture of aconite in doses 
of one drop every hour was given to the older children until ten 
drops had been given. It produced a fairly free diaphoresis and 
made the patients more comfortable. A grain of calomel in divided 
doses was given early in the attack, one-tenth of a grain being 
given every hour. The duration of the acute symptoms was ordinar- 
ily from twelve to twenty-four hours; the entire duration of the 
illness ranging from five days to one week. In the youngest child, 
with effusion, absorption appeared to be stimulated by the intro- 
duction of the needle and the withdrawal of a small amount of 
fluid, the remainder quickly disappearing afterward. To relieve 
the cough, small doses of codein, one-tenth of a grain every two 
hours, were given the older children. 



se:condary pleurisy 293 



SECONDARY PLEURISY 

Pleuritic inflammation, as a complication of disease of the lungs 
or as a result of disease in other parts of the body, is of very fre- 
quent occurrence in the young. Pneumonia furnishes by far the 
greatest number of cases, lobar more than catarrhal or broncho- 
pneumonia. Tuberculosis is possibly the next most frequent cause 
of secondary pleurisy, which is almost always without effusion of 
any moment. If the disease is of considerable duration, adhesions 
binding the lung to the chest wall will invariably be found at au- 
topsy. Secondary pleurisy may follow pericarditis. Such an occur- 
rence, however, is extremely rare. It has never happened in one of 
my cases. 

Secondary pleurisy may be either what is known as a dry pleu- 
risy or a pleurisy with effusion. When dry pleurisy exists, the 
pleura has lost its normal luster and is covered early in the attack 
with a slight fibrinous exudation. As the disease progresses, the 
exudation may be more extensive, resulting in thick fibrous bands 
and masses, a network oftentimes being formed in which is en- 
closed a thick gelatinous material composed largely of pus cells. 
Repeatedly at^ autopsy I have found the lung so thoroughly bound 
to the chest wall that its removal without the aid of force was 
impossible. 

In pleurisy with effusion, a fluid composed either of pus or serum 
will be found in the pleural cavity. I have never seen a case in which 
the effusion in a pleurisy secondary to pneumonia did not contain 
bacteria. The fluid upon withdrawal may appear clear, yet bac- 
teriologic examination will show that it is not sterile. It may be, 
and often is, the first manifestation of a purulent pleurisy or empy- 
ema. In the very young, rheumatic pleurisy (page 485) is extremely 
rare. I have seen but six cases in children under four years of age. 

Treatment. — The treatment of dry secondary pleurisy is usually 
that of the disease which it complicates. I have never known any 
special medication to be of any practical value. Tonics and suppor- 
tive measures generally are of service. Anything that will improve 
the condition of the patient should be brought into use. A change 
of residence from the city to the country for those who can afford 
it, or an outdoor life in the city for those who cannot avail them- 
selves of such a change is always beneficial. Counter-irritation 
to the chest with mustard or iodin will often give relief to the 
patient if there is pain, but otherwise it possesses no value. Occa- 
sionally there is a sense of "tightness " and constriction of the 
chest, which amounts to pain, and this condition mustard or iodin 
will relieve. Painting the affected area with tincture of iodin 
every second or third night has in a few cases afforded some relief. 
The administration of iodids as an aid to absorption is of question- 



294 DISEASES OF THE RESPIRATORY TRACT 

able value and is very apt to disturb digestion. The application 
of a mustard plaster (page 493), one-third mustard and two-thirds 
flour, to the bare skin over the diseased area for ten or fifteen min- 
utes, at intervals of six or eight hours, will add to the comfort of 
the patient. When after recovery from the pneumonia or the 
empyema adhesions persist, with restricted lung action, active 
exercise in the open air is to be encouraged. For younger patients 
horseback-riding, the bicycle, and breathing exercises, with active 
games in which they become interested and which require deep 
breathing, do better than anything else. The glass tubes of James, 
recommended by many, with which the child blows colored water 
from one bulb to another, have been of no value in my hands, because 
their use will not be persisted in long enough for benefit. The 
apparatupB is a toy. The child soon tires of it, as of any toy, and 
its use will be discontinued. 



PRIMARY TUBERCULOUS PLEURISY 
Primary pleurisy due to tuberculous infection is exceedingly 
rare in children. I have seen but one such case, and that in a child 
two years of age. Three ounces of fluid were removed from the 
chest; in four weeks signs of infiltration appeared in the lung; 
and in eight weeks after the attack of pleurisy the child died from 
general tuberculosis. The treatment is the same as for pulmonary 
tuberculosis. 

EMPYEMA 

By empyema we understand a collection of pus in the pleural 
cavity, the pus being the product of an inflammation of the pleura 
which has become infected with pathogenic organisms. Bacterio- 
logic examination of the pus shows the pneumococcus to be present 
in pure culture in a large percentage of the cases. The strepto- 
coccus and staphylococcus, alone or in combination with the pneu- 
mococcus, are seen less frequently. The tubercle bacillus is rarely 
a factor in empyema of the young. In fifty-one cases I have seen 
but one in which it was present. Empyema is rarely a primary 
disease. It is usually secondary to pneumonia, only very rarely 
to a suppurative process in another part of the body. In all my 
own cases it followed pneumonia, and if an accurate history were 
obtainable this would be the record of fully 95 percent of the cases. 

The development of the average case of empyema would be very 
much as follows: The child had catarrhal pneumonia or broncho- 
pneumonia, running the usual course as to fever, respiration, pulse, 
and prostration, and after a time, from six to twelve days, an im- 
provement in the symptoms was noticed, the pulse and respiration 
became slower, and the child brighter. For twenty-four hours 
the temperature range was lower. During the height of the pneu- 



EMPYEMA 295 

monia it was perhaps 104° or 105° F., now it ranges from 100° to 
102° F., occasionally dropping to 99° F. Such a temperature con- 
tinues for a few days, when it is noticed that it is lower in the morn- 
ing than in the evening, although* the evening temperature may 
not be over 102° F., perhaps occasionally reaching 103° F. The 
child coughs, the pulse is rapid, 120 to 140, the respirations accel- 
erated, 40 or over. The appetite is poor. These symptoms, with 
progressive emaciation, may continue for weeks if the condition is 
not recognized. 

The course of development of an empyema after a lobar pneu- 
monia is somewhat different. The crisis occurs and the tempera- 
ture falls to normal; all goes well for a few days, — four or five, 
perhaps, — when a slight evening rise occurs. The temperature 
is lower the next morning, but not quite normal. The following 
evening it is higher than the preceding and the next evening it is 
still higher. Such a temperature range is almost pathognomonic 
of empyema. 

Empyema is often mistaken for tuberculosis, malaria, typhoid 
fever, or unresolved pneumonia. An enumeration of the points 
necessary for making a differential diagnosis is not within the scope 
of this work. It may be said, however, that when the physician 
is in doubt, the aspirating needle should always be used (Fig. 28). 
If the needle is sterile — and there is no excuse for its being other- 
wise — and if the skin is properly prepared, there is no danger of 
infection. The skin should be prepared as follows: A thorough 
scrubbing with tincture of green soap should be followed by scrub- 
bing with a solution of bichlorid of mercury, i : 2000 ; this, in turn, 
is followed by washing with alcohol, which is then applied on absor- 
bent cotton and allowed to remain for at least one minute at the site 
of the proposed puncture. It is well to use a large needle, so that 
in case the pus is thick it will the more easily pass through it. The 
child should be held in an upright position, the needle introduced 
at the site of the greatest dullness. After the withdrawal of the 
needle, adhesive plaster should be placed over the wound. 

Treatment. — The pus being located, operation is the only means 
of treatment. Aspiration of the pus should not be considered a sub- 
stitute for incision. In a recent case in a young child under two years 
of age an incision with local anesthesia is all that will be required. 
In older children, or in a prolonged case in a young child, a resec- 
tion of the rib is to be advised as furnishing a much freer drainage. 
Occasionally cases are seen among older children in which, on account 
of a very severe, persisting pneumonia, it will not be safe to use 
a general anesthetic. In such cases an incision may be made under 
cocain — a 4 percent solution being injected into the skin at the site 
of the proposed incision. Such an operation will relieve the imme- 



296 



DISEASES OF THE RESPIRATORY TRACT 



diate symptoms — the displacement of the heart and the difficult 
breathing. The resection of a rib may safely be undertaken after 
a week or two, when considerable improvement will have taken place 
in the general condition. As soon as the cavity is opened, two 
half-inch drainage-tubes from two to four inches in length joined 
with a large safety-pin are inserted. Gauze is packed around the 
tubes and against the skin, and upon this the pin rests. Sterile 
gauze is placed over the end of the tubes as soon as possible after their 
introduction, in order to prevent a too free escape of pus. When 
the pus is allowed gradually to escape, much less shock will be 
experienced. Over the gauze two or three layers of absorbent 
cotton are placed, and over this the bandage. The dressing should 



^-%, 




Fig. 28.— Potain's Modification of Dieulafoy's Aspirator. 



be changed every day and the tubes shortened as the lung expands. 
This expansion will be indicated by the resulting outward displace- 
ment of the tubes. After the evacuation of the pus, the pulse usu- 
ally falls to normal or nearly normal, where it remains. Occa- 
sionally, however, cases are seen in which this expected result 
does not follow the operation. 

Illustrative Cases. — In one of my cases the operation was followed 
by a free discharge of pus, but with no relief whatever to the symp- 
toms. An examination of the chest revealed at the apex of the lung 
a pocket of pus which had become walled off by adhesions. The 
case was one of three months' duration when it came under my 



DOUBLK EMPYEMA 297 

care. A second operation removed about six ounces of pus, but 
the child died from exhaustion about twenty-four hours after- 
ward. Autopsy showed that the pleural cavity was divided into 
two distinct pus sacs by a firm band of adhesions. 

In another case, that of a girl of five years, on account of the re- 
duced condition of the child, — the empyema following a pneumonia, 
— an incision was made instead of a resection of the rib. The temper- 
ature fell to normal and all the symptoms improved for a few days, 
when an evening rise to ioi° F. and over was noted which in two or 
three days reached 103° F. There was a discharge which saturated 
the dressings, although they were changed every three or four hours. 
Our inability to locate an independent pus pocket, the continued 
fever, and a strong odor to the discharge, suggested the proba- 
bility of insufficient drainage. In spite of the fever, the child having 
gained considerably in strength, a second operation was decided 
upon to enlarge the wound. She was anesthetized and two inches 
of rib removed, when quantities of necrotic fibrinous material were 
found in the pleural cavity. These were removed with the finger 
and dressing forceps, when the temperature immediately fell to 
normal and the child made a perfect recovery. Irrigation of the 
cavity had been of no avail. 

Ordinarily the tubes should not be removed until from four to 
six weeks after the operation. They should remain in position until 
a free respiratory murmur is heard all over the affected side up to 
the site of operation in the chest wall. When the lung is fully 
expanded, the tubes will be forced out and found in the dressings. 
Irrigation of the pleural cavity is not to be advised as a routine 
measure, and with sufficient drainage it will not be necessary. The 
cases which require irrigation on account of continued fever and 
insufficient discharge require a resection of the rib. Should a 
second operation be refused, or be inadvisable, on account of the 
tender age or the general weakness of the patient or on account of 
some complication, such as a pericarditis, a daily irrigation with 
a sterile normal salt solution may be undertaken. 

DOUBLE EMPYEMA 
Two of the fifty-one cases of empyema which I have seen were 
bilateral, both pleural sacs being involved. In such cases both sides 
should not be opened at the same time, on account of the danger 
of collapse of the lungs. There are usually adhesions present suf- 
ficiently strong to prevent this, but we have no means of knowing 
this beforehand. In both of my cases, the left pleural cavity was 
opened first, in order to relieve the pressure upon the heart and 
the great vessels. In one case a considerable quantity of pus was 
removed from the right side by aspiration, at the time of the opera- 
tion on the left side. The right side was operated upon four davs 



298 DISEASES OF THE RESPIRATORY TRACT 

later, by which time sufficient adhesions had formed to prevent 
collapse of the lungs. The patient, a boy of two years, made an 
excellent recovery. 

The second case was one year of age. Pus had been present 
in both sides for a considerable time. The left side was opened 
first. The sac on the right side was smaller than that on the left, 
and was operated on by incision three days later. The child was 
very much reduced by the protracted illness. In spite of the 
free daily irrigation of both cavities the typical temperature per- 
sisted until death, probably on account of the very extensive sup- 
purating surfaces. The child died from exhaustion twelve days 
after the second operation. 

EMPYEMA NECESSITATIS 
Spontaneous rupture of the pleural sac may occur in cases of 
empyema of considerable duration which are not properly diagnosed, 
or not operated upon, if diagnosed. Cases of this nature have 
been reported in which the pus ruptured into the esophagus, into 
the bronchi, or through the diaphragm into the peritoneal cavity. 
In two of the cases seen by me spontaneous rupture occurred. In 
the first, pus ruptured into the bronchi. The patient was a well- 
nourished boy three years of age. The pus was sacculated over 
the anterior portion of the left lung. The parents, not particularly 
intelligent people, objected to the operation, and while it was under 
consideration by them, two or three days after the diagnosis was 
made, the pus ruptured into the bronchi and was discharged from 
the mouth in large quantities during a coughing paroxysm. The 
child made an uninterrupted recovery. The other case, a boy 
of two years, came under observation for a soft, fluctuating swelling 
the size of a small orange, on the right side immediately below 
the nipple. Exploration with a hypodermic needle showed pus. 
An incision was made and about three ounces of pus discharged. 
When the sac was emptied it was found to communicate with the 
right pleural cavity by an opening between the seventh and eighth 
rib. The wound was dressed and the child recovered without 
further complications. 

PULMONARY TUBERCULOSIS 

Pulmonary tuberculosis in young children under the fifth year 
of age rarely occurs independent of tuberculosis elsewhere. At 
this early period of life the disease is usually acute and fatal. After 
the fifth year, particularly after the seventh or eighth year, the 
disease assumes the characteristics which mark its presence in the 
adult. Even at this age it is by no means of frequent occurrence. 

As with the adult, so with the child, the earlier the disease is recog- 
nized and the earlier the treatment is begun, the better will be the 



PULMONARY TUBERCULOSIS 299 

result. The advantage offered by the ophthalmic and the von Pir- 
quet reaction is most apparent in this connection. The discovery 
of tubercle bacilH in the sputum should not be required, before 
beginning rigid therapeutic measures. Loss in weight, cough, and 
the characteristic, locahzed, auscultation signs, however slight, are 
sufficient to warrant active treatment. Given, for example, an apex 
involvement in a child from eight to ten years of age, with the ad- 
vantages which will be mentioned, and the prognosis is better than 
in adults with equal pulmonary involvement, who have equal advan- 
tages. 

Treatment. — Climate. — For those who are so situated financially 
as to have the advantages of an equable climate, a change of resi- 
dence or sanitarium treatment should be provided. A dry climate 
of equable temperature that will allow the tuberculous child to 
spend the greatest number of hours in the open air is the best 
climate for the patient. The climate of southern New Mexico and 
Arizona is best for these cases. I have had children do well in the 
Adirondacks and in Sullivan County, New York, but the severity 
of the winter makes these localities less desirable. 

Diet. — Equally, if not more important than climate, is the nutri- 
tion of the patient. This must be raised to the highest possible stan- 
dard, but there should be no overfeeding — a procedure of no value in 
any disease in the young. My patients have improved most on a 
high-proteid diet of milk, meat, and eggs, and a high-proteid cereal, 
such as oatmeal, and the legumes, — dried peas, beans, and lentils, — 
which are given in the form of a puree. I have found it advisable 
not to insist that a definite amount of food shall be given in twenty- 
four hours, but the mother or nurse is told that these foods, prepared 
in different ways so that the child will not tire of them, are to form 
a considerable part of the diet. Green vegetables, fruits, and plain 
desserts are given to furnish variety and to stimulate the appetite. 
When three meals a^ day are given, with, perhaps, a glass of milk in 
the middle of the afternoon, I have been able to maintain better 
nutrition than with more frequent feedings. Forced feeding in 
children often defeats its own purpose by producing disgust for 
or intolerance of food. The child should be fed on nutritious food, 
for which an appetite must be developed ; for, inasmuch as recovery 
is dependent largely upon nutrition, the question of appetite and 
food capacity is of paramount importance. Candy, sweet crackers, 
and other harmful articles should not be allowed. In order to 
satisfy the candy craving, a small quantity of sweet chocolate may 
be given after the noonday meal. The best appetizers that we 
can furnish the child are reasonable exercise, entertainment and 
play that does not fatigue, and fresh air in abundance, and upon 
our ability to supply these requirements depends, to a large degree, 
the outcome of the case. 



300 DISEASES OI^ THE RESPIRATORY TRACT 

Tenement Cases. — The majority of the cases of pulmonary tuber- 
culosis in children cannot be sent to sanitariums or to health resorts. 
They must be treated in their homes. This I have done successfully 
in New York city even among the tenement population. The basic 
principles of management are a properly directed life, good food, and 
fresh air. These are the weapons for fighting the enemy, regard- 
less as to whether the residence is among the rich or poor, in town 
or country. It is, however, among the tenement population that 
we experience the greatest difficulty. It is not enough to tell these 
people how the child is to be fed. The feeding as directed entails 
considerable expense, and the parents may not be able to meet 
it. After personal investigation, which should be made in every 
case if it is demonstrated that proper nutrition or suitable clothing 
are impossible, I explain the situation to some charitably inclined 
person of means, and have yet to know of an instance where cloth- 
ing and a small but sufficient weekly food-allowance were not 
forthcoming. To the best of my knowledge the child himself has 
always had the benefit of the charity, and I have investigated such 
cases closely. An allowance of twenty-five cents a day for fresh meat 
and milk has oftentimes furnished what was required to bring the case 
to a favorable termination. The uselessness of much of our medi- 
cal advice to the poor would, on slight reflection or a little investi- 
gation, be apparent. The physician should not trust to chance 
for results, but should act so as to make results. In addition to 
the diet above outlined, the advantages of an outdoor life, and 
the means by which fresh air may be obtained all the year round, 
are fully explained. Any simple direction as to what may appear 
to be a radical procedure is rarely carried out without a rational 
explanation of its necessity. During the daytime the child is kept 
outdoors. In the park or in the streets is better than in the 
house. Close, tightly sealed, sleeping apartments at night, however, 
will undo the good of the outdoor life during the day. The mother 
is told to have the child sleep alone in the largest room of the apart- 
ment, and always in a room in which the windows are opened. 
This is usually possible. A sponge-bath or tub-bath is given the 
child at bedtime, followed by a brisk rubbing with a towel. If 
there is much emaciation, an olive-oil or goose-oil inunction follows 
the salt bath. Sometimes these directions are followed implicitly; 
at other times they are forgotten. It is astonishing, however, what 
rapid improvement will follow, when a tuberculous child of the 
tenements is given the benefit of fresh air, day and night, with 
suitable food and cleanliness, even though it is in New York city. 

Tonics. — Among the more fortunate classes the same treatment 
is to be carried out. In these, however, we see fewer cases. The 
usefulness of drugs depends to a large degree upon an increase of 
food capacity which their use may cause. Either of the prescrip- 



I 



BRONCHIECTASIS 3OI 

tions written below may be alternated with cod-liver oil and malt, 
each being given for five days. For a child from seven to twelve 
years of age, the following are useful restoratives and appetizers: 

I^. Tincturae nucis vomicae gtt. Ixxij 

Saccharinse gr. iss 

Aquae qs. ad o iv 

M. Sig. — One teaspoonful every two hours. (Six doses daily.) 

I^. Ferri et quininae citratis gr. xxiv 

Vini xerici giv 

M. Sig. — One teaspoonful in water three times a day after meals. 

I^. Tincturae nucis vomicae gtt. Ixiv 

Extracti ferri pomati gr. vj 

Quininae bisulphatis 5 j 

M. ft. capsulae No. xxx. 

Sig. — One after each meal. 

If night-sweats are present, from 2-io to jii) grain of atropin 
given at bedtime will often furnish relief. The dangers of infecting 
others is fully explained to those in charge of the patient, kissing and 
fondling are forbidden. 

Care of the Sputum. — Various devices for collecting the sputum 
may be obtained in the shops. A cheap and effective way is the use 
of a Japanese paper handkerchief, which, when used, is at once 
placed in a paper bag, the bag and its contents being burned at the 
close of the day. 

BRONCHIECTASIS 

Bronchiectasis consists of a dilatation of the bronchi, such dila- 
tation being usually sacculated or cylindrical in form and always 
associated with an interstitial pneumonia. In a child eighteen 
months of age who died from bronchopneumonia of three months' 
duration with terminal sepsis, there were several small cylindrical 
dilatations. One of these with a capacity of six drams was found 
in the right lung. 

Treatment. — The treatment of the condition is the treatment of 
interstitial pneumonia, and little can be accomplished with the use of 
drugs except such as will improve the nutrition of the patient. Chil- 
dren with this unfortunate pulmonary disease should take up their 
permanent residence in a dry climate such as is furnished by Colorado 
or New Mexico. A visit of a few months or a year is of but little 
service. I have used the iodids and the bichlorid of mercury for 
months without any appreciable improvement, in two of these cases 
that could not be removed from town. The citrate of iron and 
quinin, one grain in a dram of sherry wine, makes a good appetizer 
for these cases. It may be given in one-fourth glass of water after 
meals. Its use can with advantage be alternated with the syrup 
of the hypophosphites (Gardner), one to three drams being given 



302 DISEASES O^ THE RESPIRATORY TRACT 

daily in one-half glass of water after meals. Cod-liver oil may be 
used with advantage for ten days out of a month. Its continued 
use sometimes is contraindicated, as it is apt to interfere with 
digestion. 

In one of the cases above referred to, the iron was given for ten 
days, hypophosphites for ten days, and the oil for ten days, when 
the procedure was repeated. The patient continued to look well, 
gained in weight, and remained under treatment until he took 
up an occupation and passed from observation. The condition of 
the lung had remained unchanged, the only active manifestation of 
the disease being the expectoration of considerable non -tuberculous 
pus every morning on rising. 

The usual outcome of those cases which have not the advantage 
of climatic influence is fatal. Death usually results from tubercu- 
losis or from a septic process in some other portion of the body. 



DISEASES OF THE HEART 

PERICARDITIS 

Pericarditis other than as a manifestation of rheumatism is 
to be regarded as secondary to a diseased process in some other 
portion of the body. 

Treatment. — As far as treatment is concerned, cases of peri- 
carditis may be divided into two groups, those of rheumatic origin 
and those due to the invasion of the known pathogenic organisms. An 
immense majority of the cases of dry pericarditis and of pericarditis 
with effusion are of rheumatic origin. The pericarditis usually is 
associated with endocarditis, or some other evidences of rheumatic 
infection are present. As a manifestation of rheumatism, peri- 
carditis may precede, be associated with, or follow inflammation 
of the endocardium. The general and specific drug management 
of pericarditis is largely the same as for endocarditis (page 305). 
The ice-bag is used as in endocarditis, but blisters are not applied. 
They are of very doubtful utility and disturb the child consider- 
ably, not only when they are being applied but for days after- 
ward. When pericarditis occurs without marked endocardial 
involvement, which is rare in the young, prolonged rest in bed is 
not so essential. 

Drugs. — For the excessive rapidity of the heart action which 
is usually present, the tinctures of strophanthus and aconite are 
of a great deal of service. For a child three years of age, one- 
half drop of the tincture of aconite and one drop of the tincture 
of strophanthus can be given at two-hour intervals, but not to ex- 
ceed six doses should be given in twenty-four hours. After the 
third year, one drop of the tincture of aconite and two drops of the 
tincture of strophanthus may be given at two-hour interv^als, six 
doses in the twenty-four hours. For the extreme restlessness which 
often exists, codein or paregoric may be given. For a child under 
two years of age, paregoric is safer. It may be given in doses of 
from ten to twenty drops and repeated when indicated at intervals 
of two or three hours. Older children, between the second and sixth 
years, should be given codein in doses of from one-tenth to one- 
sixth grain. After the sixth year, one-fourth grain may be given, 
to be repeated at three-hour intervals only, and not more than three 
doses given in twenty-four hours. As soon as the diagnosis is made, 
if the case is of rheumatic origin it is advisable to begin with the sali- 
cylate of soda (wintergreen) or aspirin, in order to prevent an effu- 

303 



304 DISEASES OF THE HEART 

sion into the pericardial sac. For those under three years, fourteen 
to twenty grains of the saHcylate of soda or aspirin should be given 
daily with twice the amount of the bicarbonate of soda. As the 
salicylate is liable to cause some gastric disturbance, it should 
never be given, when the stomach is empty, except in milk or with 
some other food ; four grains of the salicylate is as much as should be 
given at one time. After the third year, larger doses may be given. 
At the tenth year, forty grains may be given daily in divided doses, 
always in solution, observing the same precautions as to giving it 
after meals. It is impossible and entirely unnecessary in this 
country to give the large doses of the salicylate which are given 
abroad. 

In delicate children and in those in whom the salicylate is not 
well tolerated, aspirin may be substituted or the salicylate may be 
given by the bowel, using fifteen grains at a time, observing the 
precautions of diluting it with at least four ounces of water and intro- 
ducing it through a rectal tube which has been inserted at least 
nine inches. The apparatus shown in Fig. 19 is a convenient 
means of injecting the solution. It should not be given oftener 
than twice daily and should immediately follow an irrigation of the 
large intestine. In the comparatively infrequent cases which occur 
as complications of the infectious diseases, the salicylate treatment 
is not to be advised unless there is some suspicion of rheumatism 
in the case. The other methods suggested are to be carried out, 
with the hope that the disease may be controlled. It is in this 
type of case that the ice-bag is particularly serviceable. In the 
event of the effusion becoming so excessive as to interfere with 
the heart action, producing orthopnea and cyanosis with feeble, 
irregular pulse, operation on the pericardium, such as aspiration, in- 
cision, and drainage, is to be considered, although in the few opera- 
tive cases which I have seen I have not been impressed with its 
great usefulness. On the other hand, I have seen cases, in which 
there was an excessive accumulation of fluid, recover under less 
radical measures. When it becomes evident that pus is present 
in the sac, incision and drainage may be attempted, as the case 
will surely be fatal if the usual methods are pursued. 

ACUTE ENDOCARDITIS 

Endocarditis is seen more frequently between the ages of three 
and ten years than at any other period of childhood. In probably 
95 percent of the cases it is of rheumatic origin. It may occur as 
a complication of diphtheria, scarlet fever, or any other of the in- 
fectious diseases. In two of my cases it was associated with a severe 
grippe infection. When due to rheumatism, there may be other 
manifestations of the disease, or the endocarditis may be the only 
active evidence of rheumatism. The patient, on close questioning 



ACUTE ENDOCARDITIS 305 

as to his personal history, will usually give evidence of a rheu- 
matic tendency in previous attacks of rheumatism, frequent anginas, 
tonsillitis, chorea, or growing pains, or there may be a family history 
of rheumatism. 

Treatment. — Rest in Bed. — Whatever the nature of the infection, 
and whether mild or severe, one rule — that regarding quiet and rest — 
must be followed in all. The child must remain in a recumbent posi- 
tion in bed, the bedpan being used to receive the discharges. The 
heart must be given as little work to do as possible. The use of the 
arms and the hands should be discouraged, particularly early in the 
attack, as it is at this time that the greatest damage is done to the 
heart. Reaching from the bed to the floor or to the table or chairs 
should be forbidden. 

Diet. — The diet should be largely of fluids, administered in com- 
paratively small amounts, at intervals more frequent than in 
health. The bowels should move once daily. If a laxative is 
necessary, a saline should be given. A Seidlitz powder or mag- 
nesium citrate is usually effective. Distention of the stomach, 
whether by gas or by food, causes pressure on the heart and increases 
its labor. It is my custom, in these cases, to give five feedings 
in twenty-four hours, and not more than eight ounces at a feeding. 
Four ounces of milk with four ounces of gruel (see formula No. 2) 
with zwieback or toast, is the usual means of feeding. In order to 
vary the diet, a weaker gruel, No. i, flavored with an ounce or two 
of chicken or mutton broth, may be given, or a gruel of the same 
strength may be given plain, with sufficient salt to make it palatable. 
As the case progresses, and the child improves, eggs, bread and but- 
ter, stewed fruit, poultry, fish, and plain puddings may be added 
to the diet. With the freer feeding, the number of meals should be 
reduced. 

The Ice-hag. — A screw-top ice-bag, half filled with chopped ice, 
is placed over the heart and it should be our object to keep it on 
continuously. Children frequently become restless and irritable 
under this constant appHcation of the ice, and in such instances it 
may be left off occasionally for from one-half hour to one hour. 

Drugs. — In endocarditis following diphtheria or the exanthemata, 
the use of drugs is of little benefit; even the salicylates seem to 
have no beneficial effect upon these patients. For the excessive 
rapidity of the heart action which is sometimes noted, the tinc- 
ture of strophanthus is more effective than any other drug. Two 
drops may be given at intervals of from three to six hours to 
children from five to ten years of age. If there is much excitability 
and restlessness, codein \ grain, or eight grains of sodium bromid 
may be given at sufficiently frequent intervals to control the 
condition. While every case of non-rheumatic endocarditis is serious 
as regards its possibilities for permanent damage, not every case, by 



■fia^BBSitti 



3o6 dise:asks 01^ the: hkart 

any means, is of sufficient severity to demand other treatment than 
the ice-bag, rest, and an easily digested diet. It is often the milder 
cases that give us the gravest sequelae, on account of the lack of 
objective symptoms. For this reason it is difficult to make parents 
appreciate the gravity of the disease, and the child is given liberties 
which should never be allowed. 

Anti-rheumatic Treatment. — Every case of endocarditis,- under my 
care, which is not directly associated with one of the infectious diseases, 
is considered and treated as though it were rheumatism, which, as pre- 
viously mentioned, it almost invariably is. Sodium salicylate and so- 
dium bicarbonate are early brought into use. For a child of from five 
to ten years of age, from three to five grains of sodium salicylate are 
given after each feeding, five times daily, with an equal quantity 
of sodium bicarbonate. The drugs may be given in capsules or 
in solution. If the sodium salicylate is not well borne by the stomach, 
aspirin may be given in equal dosage. The salicylate should be 
given with occasional intermissions of a day or two, until the urgent 
symptoms, such as fever, rapid heart, and dyspnea have subsided. 
The dosage should then be varied, ten grains being given daily for 
five days out of fifteen. A child who has once had rheumatic 
endocarditis should be kept under close observation and the parents 
warned as to the possibilities of a second attack. 

Illustrative Cases. — In a private case in spite of anti-rheumatic 
treatment, during the intervals, four distinct attacks have occurred 
during the past five years. A dispensary patient at the New York 
Polyclinic had his first attack when four years of age. So prominent 
was his rheumatic tendency that during the next four years, regard- 
less of active anti-rheumatic treatment and a careful diet in the inter- 
vals, he had eight distinct attacks of endocarditis and died from the 
heart involvement in his eighth year. There were other manifesta- 
tions of rheumatism in his case, and on both sides the family for 
several generations had been markedly rheumatic. 

Recurrence. — Inasmuch as a recurrence is very probable, the 
patient should, even while in apparent health, have the benefit of 
a restricted diet, being allowed red meat but twice a week and 
a minimum amount of sugar. During five days out of each month, 
he should receive ten grains of sodium salicylate and ten grains of 
sodium bicarbonate, daily. This scheme of medication should be 
continued for at least two years, and much longer if the patient 
shows any rheumatic tendency, such as pains in the legs or repeated 
attacks of tonsillitis. As to the length of time during which absolute 
rest in bed is to be enjoined, every case must be decided for itself. 
The time in bed for my primary cases is from six weeks to three 
months. In one case, that of a boy who had had a very severe 
second attack, walking was not allowed for six months, the patient 
using a wheel-chair instead. 

The rapidit}^ of the heart's action is the best means of deciding 



MALIGNANT ENDOCARDITIS. MYOCARDITIS 307 

when the patient shall be allowed to walk. In a case of moderate 
severity, the heart's action, which has been rapid, 140 to 160, gradu- 
ally becomes less frequent. The temperature, perhaps, continued for 
only a week or ten days. 

Convalescence. — ^When the pulse-beat is reduced to 100, which is 
not to be expected earlier than from the fourth to the sixth week, the 
patient is allowed to sit in a reclining chair. Previous to this, while in 
bed, he is gradually accustomed to an elevation of the head by the 
addition of an extra pillow for an hour or more daily. The patient is 
allowed greater freedom when it is found that he can be indulged in 
it, and the heart kept below the 100 mark. The above scheme of 
management may seem unnecessarily severe, but we must remember 
the importance of the heart in the economy, and see to it that if 
the patient cannot have a perfectly sound heart, it shall be damaged 
as little as possible. It thus becomes a question of observing every 
precaution that will tend toward the best possible outcome, no 
rnatter how drastic such requirements may be. 

MALIGNANT ENDOCARDITIS 
Malignant or septic endocarditis is rare in children. I have 
seen but three proved cases. One occurred with scarlet fever, 
one with diphtheria, and one followed what had apparently been 
a tonsillitis. In this there was an irregular intermittent type of 
temperature with gradually increasing prostration and emaciation. 
In one the temperature frequently reached 105° F. A systolic 
murmur was present in two cases, apparently from the onset; in 
the other it appeared three days before death, and until this sign 
developed, a diagnosis was not made. The cases were all fatal. 
I know of no treatment that is of value other than in meeting the 
symptoms as they arise, with hypodermatic stimulation, suitable 
nutrition, and antipyretic measures applied to the skin in the form 
of cool packs with rest in the recumbent position. 

MYOCARDITIS 

Myocarditis of a mild degree is probably of much more frequent 
occurrence than is ordinarily supposed. It may be associated with 
inflammatory conditions of the endocardium or pericardium. It is 
not here, however, that it necessarily occurs in its most severe 
form. The myocardium is most apt to become involved as a result 
of bacterial invasion of the heart muscle in cases of grave sys- 
temic toxemia, particularly after scarlet fever, diphtheria, or 
pneumonia. 

Doubtless not a few of the cases which show marked irregularity 
of the heart action, with attacks of syncope and cyanosis following or 
associated with the above diseases, are due to a myocarditis. Often- 
times the condition is thought to be a neuritis. Auscultation aids us 



308 DISEASES OF THE HEART 

very little in the diagnosis. There usually will be a weakened first 
sound, but this may occur without degenerative changes in the heart 
muscle. Persistent irregularity, with or without a tendency to rap- 
idity, during the early convalescence after the acute disease has sub- 
sided, is one of the first indications of the presence of myocarditis. It 
is often most difficult to judge accurately of the heart action of a 
child when he is awake, because of the excitement and the resist- 
ance which the physician's presence may occasion. Cases in which 
myocarditis is suspected should be examined during sleep, as to 
the rapidity and regularity of the heart. The trained nurse's report 
as regards matters of this nature is not always to be taken as clinical 
evidence. Persistent irregularity of the pulse, as before stated, is 
the earliest sign of this very grave disease, and when pronounced 
and when the irregularity continues during sleep, with cerebral 
complications excluded, the fact must be appreciated that the 
child's life is hanging by a slender thread. There are few more 
harrowing experiences than to have a child, when apparently pro- 
gressing satisfactorily on the road to recovery after a serious illness, 
die in an attempt to reach a toy or while assisting in putting on 
his clothing. 

Treatment. — Rest in Bed. — ^When the condition of myocarditis 
follows even a mild attack of one of the infectious diseases, the invar- 
iable rule of absolute heart rest, which I consider the most important 
feature in the treatment, must be insisted upon. The patient, 
whether in hospital or in private practice, is not allowed to sit up or 
even to raise his head from the pillow ; a trained nurse is kept con- 
stantly with him, so that he may be read to and thus entertained 
while physical exertion is prevented. The child is permitted to use 
his arms only, to play with simple light toys, all other exertion 
being prohibited. Other than the recumbent position, quiet, a daily 
bowel evacuation, and easily digested food, given in small quanti- 
ties, little treatment is required. It is important to keep the 
stomach free from distention with either gas or food. I prefer small 
quantities of nourishment at frequent intervals to large quantities of 
food at the usual meal- time. 

Drugs. — In more severe cases with cyanosis and dyspnea a hypo- 
dermic loaded with strychnin 5-^ grain and digitalis y^-q grain is 
kept at the bedside constantly. In one of my cases following scar- 
let fever, so urgent were the symptoms that three physicians were 
engaged for several days, each being for eight hours daily at the 
bedside, in addition to the two trained nurses, each of whom was 
doing twelve hours' duty. My cases have all been given strychnin 
with the thought of a possible associated involvement of the cardiac 
ganglion. Further and obviously, certain portions of the heart 
muscle remain free from the degenerative process and may be favor- 
ably influenced by the strychnin. For a child one year of age 2^-^ 



MYOCARDITIS 309 

grain may be given three times daily. From the first to the third 
year, ^io to y^^ grain may be given four times daily. After the third 
year the dose is subject to considerable variation, the amount depend- 
ing upon the urgency of the case. Ordinarily from -75- to j^-q grain 
may be given four times a day. If the case is very urgent and the 
strychnin appears to improve the heart action, it may be given to 
the point of producing its physiologic effects, such as fibrillary 
twitching of the muscles of the face and the backs of the hands. 
Nitroglycerin should not be used. Digitalis is rarely given to young 
children, as it is very apt to disturb the digestion if long continued ; 
temporarily in older children, it may be used with advantage. A 
child from five to ten years of age may be given from three to four 
drops daily well diluted with water and preferably after meals. The 
tincture of strophanthus may be of more service here than is any 
other drug. It will be found particularly useful in those cases in 
which there is a tendency to rapidity of the heart action. A child 
one year of age may be given one drop every two hours in the twenty- 
four; from the first to the third year, from one to two drops at two- 
hour intervals; from the third to the tenth year, from two to four 
drops may be given at intervals of from two to three hours. The 
tendency of myocarditis in children is toward recovery. How long 
each case will require strict observation, and how long the treatment 
will ultimately need to be continued, must be determined by each 
individual case. One thing to be remembered, according to my 
cases, is that the child either dies suddenly or makes a complete re- 
covery, so that as to treatment it is better to err on the side of 
caution. 

Convalescence. — I have found it safe in a very few instances to 
allow the child to sit up after six weeks. In the very severe case 
above referred to, it was not safe for the patient to sit up in bed 
until the end of the third month, and he was not allowed to walk 
until the end of the fourth month. He was under observation for 
one year, when he was discharged, and has remained well during the 
two years which have since elapsed. At the present time there is no 
evidence whatever of his former illness. A safe rule to follow is to 
keep the patient in bed, as long as the rapidity and irregularity of 
the heart exist. When the heart action in the recumbent position 
is apparently normal, the patient may be allowed to have his head 
raised by an additional pillow. In this way the head and shoulders 
are gradually raised day by day, carefully watching the effect upon 
the heart. Progress is thus made toward sitting up in bed, under 
careful supervision, until it is demonstrated that it causes no un- 
favorable influence on the heart muscle. In the same way, standing 
and walking are gradually begun. Following out this careful method 
of heart rest and being governed solely by the heart action which 
indicates the heart power, I have seen apparently hopeless cases re- 



3IO DISEASES OF THE HEART 

cover completely. Whether fibrous changes are present which may 
have a later influence, there is, of course, no means of knowing. 

CHRONIC VALVULAR DISEASE OF THE HEART 

The most important feature to keep in mind in connection with 
valvular disease of the heart in children is the source of the disease. 
The fact that in a large proportion of the cases it is due to rheumatic 
endocarditis, and that, when endocarditis has once existed, it is very 
liable to return, are points not to be forgotten ; so that our first step 
in the management of valvular defects is to discover the cause, and, 
if it is found to be of rheumatic origin, it should be explained to the 
parents that other attacks of endocarditis are very Hable to occur, 
unless means are used for their prevention. In the absence, then, 
of a history of endocarditis in association with pneumonia, diphtheria, 
or scarlet fever, which in my experience has been of rare occurrence, 
it is assumed that the valvular lesion is of rheumatic origin, even 
though there may not be, at the time, positive evidence of rheuma- 
tism elsewhere. In not a few of these children with cardiac disease 
without a history of acute rheumatism, there will be a history of 
tonsillitis, angina, coryza, asthmatic bronchitis, or chorea — all show- 
ing recurrent tendencies. The patients will often be found to have 
a rheumatic or gouty ancestry, and not infrequently they themselves 
will be heavy eaters of red meat and sugars. 

Treatment. — Our first step, then, in the management is so to 
regulate the life as to prevent a recurrence of the heart involvement. 
With this end in view, it is directed that meat be given the child but 
once every second day, and that sugar be given in great modera- 
tion. Poultry, fish, eggs and milk, and high proteid cereals may be 
given in increased amount in order to maintain nutrition. A tub- 
bath followed by a dry rub is given daily. The bowels are not allowed 
to become constipated, and moderate exercise is encouraged. 

Drugs Advised. — For five days out of each month, the patient 
is given, after meals, five grains of salicylate of soda (wintergreen) 
and ten grains of bicarbonate of soda. This with the low meat and 
low sugar diet is usually, but not invariably, sufficient to prevent a 
recurrence. In a boy who has been under my care for several years, 
and who has had three distinct attacks of endocarditis, I am obliged 
to give the above treatment for five days with but ten days' inter- 
mission. This has been continued for eighteen months, during which 
time the heart has not been affected. During the past year there has 
been no tonsillitis, while previously he had had severe attacks every 
month or two. Both sides of the family are markedly rheumatic. 

Drugs Used with Caution. — The further management of valv- 
ular disease depends to a certain degree upon the location and 
nature of the lesion. Right here I would sound a note of warn- 
ing: Because a child has a cardiac lesion he does not neces- 
sarily require digitalis. Not a little harm is done, in the treat- 



CHRONIC VALVULAR DISEASE OF THE HEART 311 

ment of diseases in children, by giving powerful drugs when they 
are not indicated. Too often in heart disease the physician feels 
his duty done when he gives digitaUs. Many times I have seen 
children who, because of some cardiac lesion, were taking digitalis 
and strychnin, while at the same time they were suffering from 
constipation, recurrent respiratory disorders, and persistent indi- 
gestion due to dietetic errors, all of which had escaped the attention 
of the physician. 

Prognosis. — Under proper management, if begun early, the prog- 
nosis in valvular disease in children is good. The heart nutrition and 
compensation in children are usually most satisfactory. I have several 
now under my care, in whom grave cardiac disease exists, without any 
disturbance of any nature whatever which is evident to those who 
come in contact with the children. In neglected cases the outlook 
is bad. This is due, first, to the tendency of the endocarditis toward 
recurrence ; and, second, to our neglect to control the activities of the 
child. The prognosis is better when the insufficiency involves the 
mitral valves alone. In such cases the activities need be but little 
curtailed; in fact, the patient is encouraged to indulge in outdoor 
exercise, but competition in games requiring unusual exertion, tests 
of speed or endurance of any nature, such as running and racing, are 
forbidden. When the patient is old enough, swimming, bicycling, 
horseback-riding, and golf are advised. In boys, when the tobacco 
and alcohol age arrives they must be told the dangers attending the 
use of either and both must be forbidden. Girls with mitral insuffi- 
ciency must be warned against excessive dancing, rope-jumping, 
tight lacing, and indiscriminate eating. With both, rational exercise 
is beneficial. 

When the aortic valves are involved either in insufficiency or 
stenosis, or when there is a considerable degree of mitral stenosis, 
the child's activities should be considerably limited. Under these 
conditions, with a view to the future, regardless of the existing satis- 
factory compensation, I forbid the bicycle, swimming, dancing, 
baseball, or any sport or game which may call for much physical effort. 
The nature of the disease should be fully explained to the parent and 
to the patient, when he is old enough to understand it, so as to secure 
his hearty cooperation, not only as related to his activities, which, 
of course, is important, but parents should be told particularly 
that a tonsillitis or an angina is a danger-signal, and that the sali- 
cylates are to be brought into use at once, even before the physician 
is summoned. A diet of plain nutritious food, with nothing between 
meals, is a very important feature in the treatment of heart disease 
in children. Ordinarily it is not well to talk over the child's ailments 
with him or in his presence; in cardiac disease, however, I explain to 
him as clearly as possible the nature of the illness, and insist that cer- 
tain measures, particularly such as relate to restriction of activity, 
shall be carried out indefinitely. I find in this way that better co- 



312 DISK ASKS OF THK HKART 

Operation on the part of the patient is secured than if he were simply 
given a hst of dogmatic "don'ts." It is my custom, further, in 
those who show aortic involvement or mitral stenosis, to advise what 
is known as "heart rest." Every day after the midday meal, with 
clothing off or loosened, the child is made to rest in a recumbent 
position for at least one hour. During this time he may sleep or 
read, as best suits his individual taste. 

Medication. — As most of the cases of valvular disease in children 
are of rheumatic origin, it will be found that the majority of the 
patients are suffering from anemia, usually in mild degree. All the 
benefits of nutrition, fresh air, and regularity in living referred to 
under Tardy Malnutrition (page 164) should be afforded these 
children. Iron alone or with arsenic is of some value here when 
given with a suitable diet. A method often followed is to give, for 
five days, the salicylate and bicarbonate of soda already referred to ; 
for fifteen days iron and arsenic, with the remaining ten days of 
each month free from medication, unless cod-liver oil is well borne, 
in which case it is usually given in combination with the extract 
of malt. Should the patient be of an age when a capsule can be 
swallowed, the following is given: 

I^. Liquoris potassii arsenitis gtt. xc 

Extract! ferri pomati gr. x 

Quininae bisulphatis o j 

M. ft. capsulge No. xxx. 

Sig. — Take one after each meal. 

If the iron produces constipation, from one-third to one-half 
grain of the extract of cascara may be added to each capsule. 

Heart Stimulants . — Aside from such tonic medication, as far as 
concerns the heart per se, drugs should not be given unless com- 
pensation fails. This may take place temporarily, regardless of the 
tiature of the lesion, after som.e forbidden exercise, or during an 
acute illness sufficient to produce prostration, and permanently, in 
those cases which for any reason do badly. In the event of defec- 
tive compensation and dilatation, the child should be kept in bed 
until the normal heart action is restored, or until it is demonstrated 
that the aid of heart stimulants is required. In these cases, particu- 
larly in those of the latter type when there is a rapid, irregular pulse, 
difiicult breathing on excitement, and dropsy, the time-honored 
remedy, digitalis, is to be brought into use. In children I prefer to 
use the tincture. For a child from five to ten years old, from three 
to five drops may be given after meals, three or four times daily. 
The drug, because of its well-known irritant effects upon the stomach, 
should be given considerably diluted. Its beneficial effects will be 
noticed first in the relief of the dyspnoea, the pulse becoming regular 
and of increasing volume, and later in the increased secretion of 
the kindeys and the disappearance of the edema. The amount of 
digitalis given should be reduced as soon as the condition of the 



CONGENITAL HEART DISEASE — ABUSE OF HEART STIMULANTS 313 

patient will allow, but it should be continued for a considerable time 
after he is up and about. The only contraindication to the use of 
digitalis in children is its effect upon the stomach. This is often so 
unfavorable that it causes a loss of appetite, in which case its ad- 
ministration should be discontinued. In this event the tincture of 
strophanthus, which is referred to repeatedly in this work, as a heart 
stimulant, may be substituted in the same doses. In case a cardiac 
stimulant is necessary for a considerable time or permanently, I 
have had satisfactory results by alternating the digitalis with the 
strophanthus, giving each for five days. The child, however, who 
requires constant cardiac stimulation promises but little for the 
future, and few of my cases have survived the eighteenth year. 

CONGENITAL HEART DISEASE 
The majority of the cases of congenital heart defects which have 
come under my observation have died before the second year, usually 
from some intercurrent disease. Patients who pass this period of 
life rarely reach the sixth year. When the child becomes active in 
physical exercise, such as in climbing stairs and in play, dilatation of 
the right heart results. In two of my cases presenting such a 
course death took place suddenly in an attack of orthopnea and 
cyanosis. It may, however, be delayed until the child develops one of 
the infectious diseases, such as measles or scarlet fever or diphtheria. 
But little is to be said as to treatment. During the first year or two 
no treatment is necessary. Later, if the child survives, rest, an 
easily digested diet, morphin or other sedatives, with cardiac stimu- 
lation hypodermically, may give symptomatic relief. 

ABUSE OF HEART STIMULANTS 
Probably the heart stimulants, such as alcohol, strychnin, digi- 
talis, and strophanthus, are given unadvisedly with greater fre- 
quency to children than is any other form of medication. If given 
needlessly, they are harmful indirectly, in that when the time for their 
use really arrives, the system having become accustomed to their 
action, less benefit is derived from them. All forms of cardiac 
stimulants are of temporary value only. In some patients the stimu- 
lant effect of drugs will be exhausted quicker than in others. The 
common practice of giving heart stimulants, simply because a child 
has pneumonia, typhoid fever, or diphtheria, is a very bad one. For 
giving these drugs to the best advantage, there should be one special 
indication and only one — the evidence of heart weakness. A very 
rapid heart, above 150 beats to a minute in a sleeping child, may 
require help, for otherwise it may become exhausted because of the 
rapidity of its action. Pronounced weakness of the first sound and 
the accentuation of the second sound call for stimulation. When 
the heart action is irregular or intermittent, and when cyanosis de- 
velops, heart stimulants are called for. 



CONTAGIOUS DISEASES 

CARE TO BE EXERCISED BY THE PHYSICIAN IN VISITING 
CONTAGIOUS DISEASES 

As a rule, physicians in attendance upon contagious diseases are 
grossly negligent as to the use of proper precautions against the 
possibility of themselves becoming mediums of infection. The phy- 
sician who, without washing his hands, makes a practice of going 
from a child ill with diphtheria or scarlet fever to patients otherwise 
afflicted, is an element of great danger in any community. While 
properly caring for a patient, close contact is necessary, particularly 
in the treatment of throat and nose cases. Not only his hands, but 
his clothing as well, may become infected. Therefore, before enter- 
ing the room in which there is a contagious disease the physician 
should remove his coat and his cuffs, if detachable, and turn up to 
the elbows the sleeves of his shirt. If a clean gown is not available, 
an ordinary clean bed-sheet will answer, this being so adjusted as to 
protect the clothing, and held in position by two or three safety-pins. 
My custom, when attending contagious diseases, is to keep in an ad- 
joining room or closet a gown which I wear while in the sick-room. 

After leaving the patient the physician should thoroughly wash 
his hands with hot water and soap, outside the sick-room if possible. 
An excuse may be offered for not wearing the gown, but there is none 
for not removing the coat and cuffs, nor for the failure to use the 
sheet, as suggested ; and none for the failure thoroughly to wash the 
hands after leaving the patient. 

QUARANTINE 
The isolation of those ill with contagious diseases is an absolute 
necessity for the protection of others. While it is advisable in cases 
of scarlet fever to remove from the house children who have not had 
the disease, and, in the event of diphtheria, all children, regardless of 
previous attacks, such removal is often impossible. Zt then becomes 
our duty to establish such a quarantine as will be effective in pre- 
venting the transmission of the disease. In order to do this, the 
child and the attendant must not come in contact with other mem- 
bers of the family, whether children or adults. If the residence is a 
city or a country house, one or two rooms on the top floor are selected 
for the patient, the room from which he was removed being carefully 
cleaned and disinfected. If the family occupy an apartment, an 
effective isolation is more difficult, but is by no means impossible. 

314 



QUARANTINE 3^5 

In such circumstances the room or rooms must be as remote as pos- 
sible from the other hving-rooms. The room in which the child is 
placed is prepared for the patient according to the instructions laid 
down on page 43. Not only should the attendant not come in direct 
contact with other members of the family, but there must be no in- 
direct contact through dishes, feeding utensils, clothing, or bed-linen. 
The dishes, knives, forks, and spoons should be placed in boiling 
water and in this way sent to the kitchen. The clothing, towels, and 
bed-linen should be placed either in boiling water or in a carbolic 
solution — one ounce to two gallons of water — before sending them 
to the laundry. Upon their arrival at the laundry they should be 
boiled at once. A chair outside the door of the sick-room may be 
used as a receptacle for the various necessities for the patient, which 
are to be removed only when the person who brought them is at a 
safe distance. 

Two isolating rooms are better than one, and if there can be a 
connecting bath-room, it is much more agreeable to the occupants. 
If two rooms are devoted to the patient, one is used for day and 
the other for night occupancy, the unoccupied room being freely 
ventilated after the removal of the child. Observing the above pre- 
cautions until the child is well, I have repeatedly carried through 
to successful convalescence cases of diphtheria and scarlet fever 
while other unprotected children have remained in the household 
during the entire illness without taking the disease. 

An incident which well demonstrates the value of proper quaran- 
tine occurred at the New York Infant Asylum., Mt. Vernon, New 
York, during my service as interne in that institution. The institu- 
tion was built on the cottage plan, two wards in a cottage. A colored 
child, an occupant of one of the upper wards, was discovered to be 
ill with scarlet fever. There was an extensive rash, considerable 
swelling of the cervical glands, and the whole aspect of the case was 
that of scarlet fever at its height. Through the negligence of an 
orderly, the child had probably been ill two or three days before our 
attention was called to him; as a consequence, thirt}^ other children 
of the ward had been exposed. In order to prevent the spread of 
the disease to the other four hundred children, it was decided to 
quarantine the ward with its children and the four attendants. 
This was done. Twenty- six children and two women attendants 
developed the disease. The quarantine, on the plan above sug- 
gested, was continued for ten weeks. The 'thirty or more children 
on the ground floor of the cottage remained there as before, but 
no other case developed in the institution. In order to prevent the 
spread of the contagion, there was no personal contact with those 
outside of the ward, except with the physician who visited them 
daily, but who always went properly protected (page 314). All 
clothing and bed-linen were boiled before leaving the ward. The 



3l6 , CONTAGIOUS DISK ASKS 

dishes and feeding utensils likewise were boiled before being sent to 
the general kitchen. 

If such isolation is possible in an institution among the careless 
and more or less ignorant, it certainly should be equally effective 
among the intelligent, who are most interested in preventing the 
spread of disease. 

When the quarantine is raised the child should receive a bath of 
bichlorid of mercury i : 3000. If the hair is cut short and sham- 
pooed with green soap, followed by the bichlorid, the disinfection is 
more complete. 

DIPHTHERIA 

Diphtheria is an infectious, contagious disease due to the Klebs- 
Loeffler bacillus. Its first manifestation is inflammation, usually of a 
mucous surface, with the production of a pseudo-membrane. Any 
of the mucous surfaces may be involved. Thus, under my own ob- 
servation, the process has involved the nasal cavities, the lips, the 
mouth, tonsils, pharynx, larynx, trachea, and bronchi. The esopha- 
gus was the seat of the pseudo-membrane in one case and the con- 
junctiva in several. The rectum or the vagina may also be the seat 
of the disease. Constitutional and other symptoms fairly character- 
istic rapidly follow the local manifestation. There is always some 
fever, but the temperature is usually low. Swelling of the glands 
at the angle of the jaw is an early and important sign if the throat is 
involved. The breath in many patients with diphtheria has a pecu- 
liarly offensive odor which occurs in no other disease. By far the 
most frequent sites of the local manifestations are the tonsils, the 
fauces, and the larynx, the nasal cavities being more rarely involved. 
It is not within the province of this book to go into details as regards 
differential diagnosis or description of the various phases of the dis- 
ease. They can be found in any text-book on children's diseases. 
What is particularly necessary, in the light of modern treatment, is 
that the physician familiarize himself with the clinical picture of the 
disease in its various phases, so as to be able to recognize it regardless 
of where or how it appears. 

Antitoxin. — Owing to our increased knowledge of the etiology 
of diphtheria and since the advent of the specific remedy, anti- 
toxin, the disease has lost much of its former terror. It is still, 
however, a considerable factor in the death-rate of all large cities. 
This is due to two causes: first, to parents who fail to appre- 
ciate the possible dangers that may arise from a sore throat and 
who neglect to call a physician early in the illness; second, to 
physicians who do not believe in diphtheria antitoxin, to those who 
timidly use it in small doses late in the disease, or to those who wait 
for positive clinical signs or a report of a culture before using it. 
Equally as necessary as is the realization of the value of antitoxin, 



DIPHTHERIA 317 

is the knowledge as to how and when to use it and when to repeat it. 
In many cases at the beginning of the disease, when the tonsils alone 
are involved, it is impossible without the aid of the laboratory to 
differentiate diphtheria from tonsillitis. I have seen case after case 
in the pre-antitoxin period in which two or three days were required 
to make a positive clinical diagnosis. In towns in which a bacterio- 
logic examination is possible it is in some instances safe to wait for a 
report from such an examination. When in doubt, a safer rule to 
follow, in those cases in which there is pseudo-membrane on the 
tonsils, is to give antitoxin at once. If the case proves to be a simple 
tonsillitis no harm will follow. I have given full doses of antitoxin 
to patients in whom we afterward learned there was no diphtheria, 
without any unfavorable results. 

Illustrative Case. — During the winter of 1 906-1 907 I was called 
to see a little girl six years old with a gray membranous patch on 
the left tonsil, the size of a thumb-nail. There was a temperature of 
101° F. The child was complaining of feeling tired and seemed 
wretched generally. There was considerable difficulty in swallowing. 
I gave at once 3000 units of antitoxin and sent to a private labora- 
tory a culture from the throat. The report reached me the next 
morning that the Klebs-Loeffler bacillus was absent. On visiting 
the case at this time I found that the membrane had extended, 
the right tonsil being covered. I repeated the antitoxin, giving 
3000 units more, and took another culture. This was sent to another 
private laboratory. Again the report was negative for the Klebs- 
Loeffler bacillus, but the culture showed a pure growth of the strep- 
tococcus. The following morning the throat began to clear, and in 
two days was normal. Clinically this case was diphtheria. There 
was no scarlatina, but there was some swelling of the glands at the 
angle of the jaw. The child showed no symptoms whatever to indi- 
cate that antitoxin had been given. 

Necessity for Promptness in the Use of Antitoxin. — ^When there 
is diphtheria and we wait for positive clinical signs or for the report 
of a culture, even though but for ten or twelve hours, most valuable 
time is lost, and it is this delay that is responsible for many deaths. 
If there is one thing, in addition to its great usefulness, that we have 
learned as to the administration of antitoxin, it is the necessity of 
giving it at the earliest possible moment in the disease and of giving 
it in full doses. 

Dosage. — After a large experience in the use of antitoxin I am 
convinced that it is often given in too small initial doses even by many 
familiar with its use. In April, 1904, I commenced to use larger 
doses, rarely giving less than 5000 units at the first injection. When 
there is membrane on the uvula, the pillars of the fauces, or the pos- 
terior pharyngeal w^all, or in the nose, we should never wait for the 
report of a culture, but a full dose of antitoxin should be given at 



3l8 , CONTAGIOUS DISEASES 

once. The antitoxin is to be repeated eight or twelve hours later if 
there is an extension of the membrane or if there is no change in its 
appearance. If the throat shows a tendency toward improvement, 
if there is a curling up and loosening of the membrane at the edges, or 
if it has taken on the granular appearance peculiar to diphtheritic 
membrane after a full dose of antitoxin, it may be safe to wait twelve 
hours longer, twenty-four hours in all, before deciding whether a 
repetition of the original dose or a smaller one is required. A dimi- 
nution in the nasal discharge in the nasal cases, a lessening of the 
breath fetor, a reduction in the glandular swelling, and a fall in the 
temperature — all are indications of improvement, but the physician 
should not rest there; the constitutional improvement, the clearing- 
up process, must be rapid and complete, and when the case shows no 
sign of improvement, more antitoxin should be given. 

A child ill with diphtheria must be looked upon as a child poisoned ; 
antitoxin is the antidote, and every case must receive enough of the 
antidote to neutralize the poison. Whether this will be supplied, 
depends upon the recentness of the infection when seen by the physi- 
cian and upon his ability to apply the remedy. In a recent, very 
severe case, in a girl eight years of age, 16,000 units were required be- 
fore the disease yielded. The first injection was given on the second 
day of the disease. In a laryngeal case in a boy five years of age, 
9000 units were given in nine hours. 

Laryngeal Diphtheria. — If, during the course of an attack of diph- 
theria or in a case which may have been diagnosed as tonsillitis, the 
voice becomes hoarse and croupy, it is an almost infallible sign that 
the process has extended to the larynx, and 7000 units of antitoxin 
should be given without delay. If, after waiting eight hours, there is 
no improvement in the laryngeal symptoms, or if they have increased 
in severity, 5000 more units should be given. Laryngeal cases re- 
quire larger and more frequently repeated doses than do those in 
which the fauces alone are involved. Cases of laryngeal diphtheria 
without previous throat involvement tax our judgment most se- 
verely. 

Differential Diagnosis. — It is by no means an easy matter to 
differentiate the croup due to an acute catarrhal laryngitis from that 
due to membranous laryngitis. The following points have aided 
me in many instances in forming a right conclusion : 

Diphtheritic Croup. Catarrhal Croup. 

Gradual onset. Obstruction intermittent with gradu- 

Obstruction persistent. ally increasing severity. 
Obstruction both to inspiration and Sudden onset. 

expiration. Obstruction to inspiration, only. 

Little or no response to emesis or in- Response to emesis and inhalations and 

halations. to sedatives. 
No response to sedatives. 

The mode of onset is, of course, not to be relied upon absolutely 



DIPHTHERIA 



319 



in differentiation. Occasionally the onset of catarrhal laryngitis may 
be gradual while that of diphtheria is sudden. In the consideration 
of a great many cases, however, the points of differentiation are of 
sufficient value to warrant the attention which has been given them. 
A safe rule to follow, in view of the urgent demand for early injec- 
tions of antitoxin, is the same as in other forms of diphtheria, i. e., 
when in doubt, inject from 5000 to 7000 units. From the gradual 
cessation of the laryngeal symptoms it is fairly safe to assume that 
the child is doing well, although the breathing may not be entirely 
free for forty-eight or seventy- two hours after the first injection. In 



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Fig. 29. — CH.A.RT Showing the Effect of Antitoxin upon the Temperature in 

L.A.RYNGEAL DIPHTHERIA. 



cases which require intubation, 7000 to 10,000 units should be given 
for the first injection and repeated the following da}^ According to 
my observation, intubation cases require 10,000 to 15,000 units even 
when antitoxin is used early, by which we understand on the second 
or third day of the disease. If this amount or more must ultimately 
be given, it is advisable to give it early in the disease. The earlier 
the injection, the less frequent will be the necessity for its repetition. 
Illustrative Case. — The chart presented in Fig. 29 well ^hows the 
effect of antitoxin upon the disease as represented by the tempera- 
ture. The case was one of a girl eight years of age, who when I first 
saw her had been ill for two days with sore throat. At the time the 



320 CONTAGIOUS DISK ASKS 

uvula, the pillars of the fauces, the tonsils, the soft palate, the post- 
pharyngeal wall, and the nose were involved. Three thousand units 
were given at once. In a similar case now I would give from 5000 
to 7000 units. An improvement in the physical condition of the 
child and in the local process kept pace with the temperature, both 
being favorably influenced by the treatment, but it required 9000 
units of the antitoxin to counteract the effect of the diphtheritic 
poison. 

Antitoxin in Non-operative Cases. — Eighty-three non-operative 
cases of diphtheria have been treated by me with antitoxin with 
doses varying from 1000 to 16,000 units, the former being given in 
one case only. Among these cases one was fatal — my first and 
only fatal non-operative case. The patient was given 1000 units 
on the fourth day of the illness. He died on the eighth day. It is 
hardly fair to include this case in the antitoxin group, as at that time 
we did not know how to use antitoxin and therefore were more or less 
timid, and the serum was not up to its present high order of efficiency. 
An early and full dosage explains the above most satisfactory results. 
Twenty-one operative intubation cases were treated with antitoxin, 
and of these eighteen recovered. One of the fatal cases died on the 
second day of the illness from a complicating lobar pneumonia. 
Another was seen in consultation on the fifth day^ intubated, and given 
3000 units at once. The child was septic at the time and died in twelve 
hours. The remaining case, also seen in consultation, was intubated 
and received 3000 units on the fifth day. The antitoxin was re- 
peated twice at twelve-hour intervals. The child died of heart failure 
forty-eight hours after the first injection. We now know that these 
children should have received at least 5000, or better 10,000, units at 
the first injection and the dose repeated at eight-hour intervals. 

In fourteen non-operative cases in which the injection was given 
on the first day of the illness it was necessary in but one case to re- 
peat the antitoxin on the following day. In all of these cases the 
throats were clear in from thirty-six to seventy-two hours after the 
first injection. Among twenty- three non-operative cases injected 
the second day, seven required a second injection on the third day, 
and in three of these a third injection was given on the following day. 
Among seven third-day-injection cases, two required three injections 
and two received two injections. 

Late Injections. — Antitoxin should always be given in diph- 
theria no matter how late in the disease the case may first be seen. 
In one case first seen by me on the sixth day, 11,000 units were 
given in three injections at eight-hour intervals. The child recov- 
ered. In another case, already referred to— the one of laryngeal 
diphtheria in a boy five years of age, who was first seen on the fifth 
day — 11,000 units were given in nine hours with prompt recovery. 
I have used the antitoxin as late as the eighth day of the disease 



DIPHTHERIA 321 

with benefit and recovery, and it is my belief that the patient 
would not have recovered without it. In order to be signally 
effective, the serum should be given not later than the third day. 
The later it is given, the greater the amount required, and the greater 
the need of repeating the injection. Considerable discredit has been 
thrown upon the antitoxin treatment by the timid and by those not 
familiar with its use. We frequently hear of cases of diphtheria 
dying after the administration of antitoxin, the patient having re- 
ceived but 2000 or 3000 units, and that amount perhaps late in the 
disease. It would be as irrational to claim that quinin is of no 
value in malaria, because three or four grains daily make no im- 
pression on the disease, as it is to claim that antitoxin is of no value 
in diphtheria, because two or three thousand units are given with- 
out beneficial results, even when administered early in the disease. 

Blood Changes Due to Antitoxin. — It has been claimed that 
antitoxin produces deleterious changes in the blood, affecting par- 
ticularly the red blood-corpuscles. Bearing on this statement we 
quote from Ewing's "Pathology of the Blood": "The red cells 
in the blood show no distinct or uniform effects from the use of 
antitoxin, although in some subjects there is a moderate reduction 
lasting a few hours. On the other hand, the use of antitoxin, by 
limiting the progress of the infection, tends to prevent further 
disintegration of the blood-cells. Within one-half hour after the in- 
jection of antitoxin the leukocytes, particularly the polynuclear 
form, if previously abundant, show a marked dissemination, and 
in most cases, although the leukocytosis returns after twenty- 
four hours, it seldom reaches its previous grade." Ewing noted a 
reduction of leukoc}i:es after antitoxin in all but two fatal cases, 
while Schlesinger found it in all of his examinations. A marked 
leukoc\i:osis is usually present in diphtheria, various writers estimat- 
ing the number in a cubic millimeter at from 25,000 in an average 
case, to 50,000 in a severe one. 

Urticaria. — In 20 percent of my cases urticaria followed the use 
of antitoxin. The most severe urticaria occurring under my ob- 
servation followed an injection of 3000 units. The earliest ap- 
pearance of the eruption was on the fifth day following the injection; 
its latest appearance, on the twenty-first day. The urticaria ap- 
parently differs in no respect from that due to other causes and the 
treatment should be the same. Among local applications, a i 
percent solution of carbolic acid, or a lead and opium wash, relieves 
the itching better than does any other measure. For internal ad- 
ministration, salicylate of soda answers better than any other form 
of medication. For a child five years old three grains well diluted 
may be given every two hours until five doses have been taken daily, 
the treatment being thus repeated every day until the rash disappears. 

When a member of a family becomes ill with diphtheria the sug- 



322 CONTAGIOUS DISEASES 

gestions in Quarantines (page 314) should be carefully followed 
out. 

Immunization. — In every case of diphtheria other children of the 
family should be immunized. Never less than 1000 units should 
be given for this purpose, regardless of the age of the child. Cul- 
tures should be taken from the throats of children and adults alikco 
If the Klebs-Loeffler bacillus is found, the case must be isolated 
and treated as diphtheria, so far as quarantine is concerned. Two 
of my cases developed diphtheria after immunizing doses of anti- 
toxin. A child nine months of age was given 3000 units and de- 
veloped diphtheria four days afterward. The patient recovered 
after a second injection of 3000 units. A boy four years of age 
was given 1000 units for immunization. He developed diphtheria in 
thirty-six hours, which was controlled by the injection of 3000 units. 
The throat was clear in forty-eight hours after the second injection. 

Choice of Antitoxin. — The author has used successfully the 
antitoxin prepared by Parke, Davis & Co., by H. K. Mulford & 
Company, and by the Health Department, New York city. 



•-,y^~*^ 



Fig. 30. — "Record" Antitoxin Syringe. 



Means of Injection. — There are several antitoxin syringes on 
the market, any one of which may be used if it will admit of re- 
peated boiling, for in every instance the syringe should be boiled 
before using. The ''Record" antitoxin syringe ^ (Fig. 30) satisfac- 
torily fulfils these requirements. Some of the private producers of 
antitoxin furnish it in glass bulbs with appliances for injecting it 
subcutaneously. The advantage possessed by this combination is 
its convenience and its safety, for as the instrument has to be used 
but once, the danger of infection by means of a syringe which is 
used repeatedly is thus avoided. 

Site for Injection. — The skin over the abdomen between the um- 
bilicus and the anterior spine of the ilium is doubtless the most 
convenient site for the injection. The skin is very loosely attached 
at this point and the serum passes freely under it, requiring very 
little force and producing no laceration of the tissues, nor does the 
soreness of the parts interfere with the child's customary position 
in bed. If the buttocks, favorite sites for the injection with 
many, are selected, the needle should be inserted well up on the 
side, so as not to interfere with the child's resting on his back. 

^ The " Record " antitoxin syringe may be obtained of James C. Dougherty, 
409 West 59th St., New York. 



DIPHTHERIA 323 

Before injecting, the skin should be thoroughly scrubbed with 
green soap and washed with alcohol. Upon the withdrawal of the 
needle, the skin should again be washed with alcohol and a piece of 
Z. O. plaster, one inch square, applied over the site of the injection. 
With these precautions regarding cleanHness there has never been, in 
my experience, a suggestion of a local infection. Wherever the site 
of the injection, care should be taken not to plunge the needle into 
the muscle; draw up the skin between the fingers and insert the 
needle horizontally. 

Remedial Measures Other Than Antitoxin. — Among the many 
remedies which have been advocated and used from time to time in 
the treatment of diphtheria, practically none remains in use at the 
present time. During the pre-antitoxin period I had abundant 
opportunity, in 103 cases at the New York Infant Asylum, to 
test the value of drugs, inhalations, vaporizing treatment, local 
applications, gargles, and sprays. In an article relating to this epi- 
demic of diphtheria w^hich was written by me several years ago, 
is the following statement: "The death-rate in the institution 
from diphtheria was large. About 60 percent mortality. In so far 
as the methods of treatment were concerned all were equally value- 
less. The mild and some moderately severe cases recovered under 
good general management. The severe cases died regardless of treat- 
ment." In other words, there was no method or scheme of treatment 
used at that time that w^as of any signal value. Happily, at the pres- 
ent time, all the old methods are forgotten. We do not need them. 
Antitoxin is a specific. The use of sprays and gargles and applica- 
tions are of value as a means of cleanliness only. For this purpose 
the throat irrigation (page 258) answers better than any other. For- 
cible irrigation of the nose should not be employed. In such cases 
the danger of forcing infected material into the eustachian tube with 
resulting secondary otitis is a real one. In small children, if the 
breathing is interfered with because of membrane or tenacious 
secretions in the nose, a few drops of liquid albolene instilled every 
hour will give as much relief as can be furnished by any other local 
measure. 

Sick-room Regime. — In the management of diphtheria the same 
sick-room regime should be followed out as in other serious diseases. 
The temperature of the room should never be above 70° F. and at all 
seasons of the year there should always be a free communication with 
the outer air by means of an open window. The child should wear 
its ordinary night-clothes and the bed-clothes should be of the same 
weight as those used in health. The nutrition of the patient is most 
important. As a rule, food is poorly taken because of the pain 
caused by swallowing. Inasmuch as but a few ounces may be taken 
at one time, it is well to give the nourishment in as concentrated a 
form as possible. Milk should be given as the chief article of diet, 
with the addition of lime-water or bicarbonate of soda. If the taste 



324 CONTAGIOUS DISEASES 

of milk is disagreeable to the patient, it may be mixed with equal 
parts of a thick gruel and well salted. Animal broths possess so 
little nutriment that it is unwise to use them. The milk, plain or 
diluted, will often best be taken if given cold or cool, even by children 
under one year of age. It will usually also be taken from a spoon 
or cup better than from a bottle, because of the discomfort produced 
by drawing on the nipple. When sufficient nourishment will not be 
swallowed, gavage (page 140) may be brought into use, or rectal 
alimentation (page 145) may aid us temporarily in maintaining nu- 
trition. The temperature is rarely high enough in diphtheria to 
require the use of any means for its reduction. In case of high 
fever the sponge-bath (page 502) or cool pack (page 503) will answer 
the requirements. When the heart action becomes weak, irregular, or 
intermittent, stimulation will be necessary. For this purpose three 
drugs are of signal value — strychnin, tincture of strophanthus, and 
alcohol. 

Intubation 
To the genius of the late Dr. Joseph O'Dwyer, of New York, is 
due the credit of perfecting this operation, which, will forever stand 
as a monument to the inestimable service which he rendered to man- 
kind. The O'Dwyer intubation set (Fig. 33) furnishes us with the 




Fig. 31.— Extubator. 

necessary instruments for the operation. Various modifications of 
the tubes, the introductor, and the retractor have been attempted 
from time to time by others, but the original perfected design of 
O'Dwyer has yet to be improved upon. 

Intubation of the larynx may be required in a retropharyngeal 
abscess, situated low on the posterior pharyngeal wall. It may be 
required in edema of the larynx and in acute laryngitis. Its greatest 
usefulness, however — that for which it was designed — is to relieve 
the stenosis of laryngeal diphtheria. Before attempting to introduce 
a tube into the larynx of the living subject the physician should 



INTUBATION 



325 



familiarize himself with the operation on the cadaver. In no other 
way can the operation safely be learned. Attempts at intubation 
by the unskilled on the living subject can result only in laceration 
and other gross injuries to the parts. 

When to intubate is a question puzzling alike to students and to 




Fig. 32.— Introductor with Tube Attached. 




Fig. 33-— O'Dwyer Intubation Set. 



many physicians. It has been variously answered, and manv at- 
tempts have been made to formulate a series of chnical manifesta- 
tions the presence of which would render the operation necessary. 
Thus, it has been said that it is indicated when there is a pronounced 
recession of the suprasternal and infrasternal regions, and when, as a 
result of stenosis, air enters the bases of the lungs but feebly or not 



326 CONTAGIOUS DISEASES 

at all. It may safely be said that intubation is never done too early, 
but it is very apt to be done too late — not too late in a great majority 
of instances to be of some service to the patient, but too late to be of 
the greatest possible service. My rule regarding intubation in laryn- 
geal diphtheria is to intubate when I see that the child is wasting 
vitality in his efforts to carry on respiration. Intubation should 
not be postponed until the child becomes exhausted in his struggle 



1 



1 





Fig. 34-— Position for Intubation. 

for air. Diphtheria is a disease in which every possible strength- 
unit must be preserved. Energy wasted in supplying air is an un- 
necessary waste since O'Dwyer has shown us how to introduce a 
tube into the lar3^nx. 

Operation. — For the operation of intubation, the patient should 
be wrapped from his shoulders to his feet in a sheet securely pinned 
from top to bottom. The older and stronger the child, the more this 
is necessary (Fig. 34). The patient is held on the lap of the nurse, 
who passes her right hand around the child's body. The child's 
head rests on the nurse's right shoulder, firmly held in position by 



INTUBATION 327 

her left hand. In large, strong children it may be necessary for a 
third person to hold the child's head. The gag being introduced, 
the operator, with instruments and hands disinfected, holds the in- 
troductor in his right hand, locates the glottis with the forefinger of 
the left, and, using it as a guide, directs the tip of the tube into the 
larynx. He must be certain that the tip is properly placed before 
exerting pressure to put the tube into position. This can readily be 
appreciated by one who has practised on the cadaver. When posi- 
tive that the tip of the tube is engaged in the glottis, gentle pressure 
will put it into position. Force should never be used, even when the 
tube is started right, for the child may require a smaller tube than his 
age indicates. This is rather unusual, however, as are the cases 
which require larger tubes than the age calls for. When the tube is 
easily coughed up, it is my custom to introduce the next larger size. 
With the tube in position, the obturator is quickly removed. I 
never trust to pressure on the shank of the introductor to disengage 
the obturator, but keep the guiding index-finger of the left hand on 
the expanded head of the tube in order to insure its remaining in 
position during the extraction of the obturator. 

Results of Intubation. — After the operation the child who has 
previously been struggling will take a deep inspiration and cough. 
One of the most welcome sounds to the operator is the sharp rattle 
produced by the passage of air through the mucus which has been 
forced into the tube. This tells him that the tube is in position and 
that speedy relief of the stenosis may be expected. The intubated 
child will usually cough vigorously for several minutes, and in so 
doing may bring up a quantity of mucus and shreds of membrane. 
I have often been astonished at the large pieces of membrane and 
the quantity of thick mucus that can pass through the compara- 
tively small lumen of the tube. In a few cases, the presence of the 
tube in the larynx has caused such a persistent cough that a seda- 
tive was required to control it. Small doses of bromid of soda — 
four grains every half hour for two or three hours, for a child four 
years of age — usually answer the purpose. The thread, looped and 
knotted, which has been attached to the tube, should be long enough 
to extend four or five inches beyond the lips. In case relief to the 
stenosis is not immediately perceptible after the operation, or if the 
breathing is made more difficult, one may be sure either that the 
tube is not in position or, if in position, that it is plugged with 
membrane, or that membrane may have become disengaged and is 
pushed downward ahead of the tube. A tube in the esophagus, 
where, in my hospital service, I have seen it placed by internes, may 
exert sufficient pressure upon the posterior portion of the larynx 
effectually to impede respiration. 

Illustrative Cases. — Several years, ago I was called to intubate a 
boy two 3^ears of age who was suffering from moderate stenosis due 
to diphtheria. The tube was easily introduced, but its introduc- 



328 CONTAGIOUS DISEASES 

tion was followed by entire cessation of respiration. The tube 
was immediately extracted by means of the attached thread and was 
found to be plugged with membrane requiring considerable pressure 
with a wooden toothpick to dislodge it. The stenosis was somewhat 
relieved as the result of dilating the parts and a removal of a por- 
tion of the membrane, but not sufficiently to furnish permanent 
relief to the patient. The tube was again introduced, followed by a 
complete relief of the stenosis. 

Displacement of the Membrane. — When membrane is dislodged 
and pushed ahead of the tube, it will usually be expelled by cough- 
ing, after the extraction of the tube. A case of this nature, follow- 
ing the withdrawal of the obturator, occurred in a child six years 
of age, whose breathing, before difficult, was impossible. The 
child struggled violently, became much excited, and, with one hand 
free, knocked the gag from its mouth. In my efforts to extract 
the tube the string broke, and while introducing the gag in order 
to use the extractor, the child's struggles and attempts at coughing 
dislodged both the tube and a large amount of membrane, one piece 
of which, enclosing the tube, came out as a perfect cast of the larynx 
and upper trachea. The relief was immediate. Re-intubation was 
not attempted nor was it necessary later. The child had been given 
5000 units of antitoxin twenty-four hours before, which helps explain 
the disiodgment of the membrane. 

Removal of the Tube. — When the patient is progressing satis- 
factorily, the question arises. How soon may this tube be removed? 
I rarely remove it before the fourth day after intubation. I find 
that when it is taken out on the second or third day, for cleansing 
purposes or otherwise, it is usually necessary to replace it. 

Necessity for Intubation. — With the introduction of antitoxin, the 
necessity for intubation has become less frequent. The free use of 
antitoxin — 5000 to 10,000 units as an initial dose, given with the 
first sign of obstruction and repeated at eight-hour intervals until 
two, three, or more doses are given — will further reduce the number 
of cases requiring intubation, making it a still rarer necessity. I do 
not feel safe in these cases until 15,000 or 20,000 units have been given. 
Fortunately, in laryngeal obstruction due to diphtheria, the stenosis 
is usually of gradually increasing severity, so that by the early use 
of antitoxin many cases are relieved before the necessity for operation 
arises. 

SCARLET FEVER 

Scarlet fever is one of the most dangerous diseases to which 
children are subject, because of its marked tendency to complications. 
We never know in a given case, whether mild or severe, what the 
morrow may bring forth. For this reason the most scrupulous care 
is absolutely necessary in the dietetic and sick-room management. 
The patient must be kept in bed throughout the entire illness, of 
from four to six weeks; i. e., from the onset, first manifested by sore 



SCARLET FEVER 329 

throat and fever, until the desquamation is completed (see Quar- 
antine, page 314). We must realize at the outset the possibilities as 
to the virulence of the infection and the complications. The death- 
rate in scarlet fever epidemics varies from 10 to 30 percent. In 
greater New York from 350 to 450 children under ten years of age 
die from scarlet fever or its complications every year. In order to 
do our full duty to the patient, we must place him in the best pos- 
sible position for successfully combating the disease. 

The Sick-room. — The sick-room should be as large as it is possi- 
ble for the family to supply. It is desirable that it be well lighted 
by two windows which will make free ventilation possible. For the 
latter purpose, the window-board (page 44) answers well. There 
should always be a direct communication with the open air, except 
when the child is being bathed or its clothing changed. Light and 
the free circulation of fresh air are absolutely necessary for the 
proper management of a severe case of scarlet fever. If possible, 
two rooms should be used — one for the day, the other for the night. 
The room which is not occupied should have the window or windows 
wide open. When nephritis, endocarditis, or otitis develops, it is the 
result of the scarlet fever poison or associated infection,and not because 
a window was left open or a few rays of sunlight streamed into the room. 

Clothing. — The child requires no extra jacket or wraps. The 
customary night-gown with the light gauze undershirt and the usual 
bed-covering is all that is required. 

Urine Examinations. — The urine should be examined for albumin 
every day. It is my practice to have the family get a few test-tubes 
and a bottle of chemically pure nitric acid. When the bus}^ physician 
has the daily specimen sent to his office or carries it home himself, 
it is sometimes forgotten, misplaced, or lost. During convalescence, 
when the daily visit is not made, the nurse or some intelligent mem- 
ber of the family can be instructed to make the test and report if 
trouble is discovered. Because of a lack of these precautions, 
nephritis may easily be overlooked until puffiness about the eyes and 
edema of the lower extremities are discovered by the attendant after 
albumin had been present in the urine for several days. 

Diet. — In the bottle-fed the food strength should be reduced one- 
half during the acute febrile stage by the use of boiled water. If the 
child is getting eight ounces of a milk mixture, four ounces of this mix- 
ture should be given with four ounces of water. In older children, 
the diet is not only considerably restricted during the acute stage, 
but during the entire course of the disease. During the acute febrile 
stage diluted milk, gruels, and orange- juice should constitute the 
diet. For a child from two to four years of age, five ounces of milk 
with five ounces of barley gruel No. 2 (see formulary, page 129) may 
be given at four-hour intervals — four to five feedings in twenty-four 
hours, which make an acceptable diet. A^'ariations may be made in 
the gruels used. Wheat, rice, and granum mav all be brought into 



330 CONTAGIOUS DISEASES 

use, made as suggested in the formulary and given with equal parts 
of milk. It is always well, in the feeding of sick children, to provide 
for some variety in the food, in order that the child may not tire of it. 
The juice of one-half an orange may be given twice daily, three hours 
after the milk and gruel feeding. For the sake of variety in the diet, 1 
occasionally allow a glass of whey or kumyss, or a glass of skimmed 
milk containing one-half ounce of lime-water. Toasted bread, zwie- 
back, or plain crackers, dry or in diluted milk, may be given occa- 
sionally. 

The exclusive milk diet in the management of scarlet fever, about 
which we have all heard and still hear a great deal, has not been as 
successful in my hands as has the foregoing. My observation has 
been that the exclusive milk diet is apt to produce constipation, 
intestinal indigestion, coated tongue, loss of appetite — in fact, the 
child "grows stale" on the milk, which is to be our dietetic mainstay 
during the weeks that are to follow. During the post-febrile period, 
slight additions are made to the diet by the use of farina, hominy, 
wheatena, and the lighter cereals, prepared as a porridge with a 
sprinkling of sugar and a little milk. The child's customary diet 
should not be resumed until four weeks have elapsed from the com- 
mencement of the attack. If the case has been a severe one, showing 
marked systemic infection, six weeks should elapse before the full 
diet is resumed. 

Bowel Evacuation. — There should be one evacuation of the bowels 
daily. If this does not take place, a soap- water enema should be 
given. If, on account of the diet and the recumbent position, there 
is a tendency to constipation, a glass of malted milk — six teaspoon- 
fuls of the malted milk to eight ounces of water — as a part of the 
evening meal will be of service in relieving the condition. The ad- 
dition of one teaspoonful of cocoa will be grateful where the taste of 
malted milk is objectionable. 

Laxatives. — As a laxative during the acute febrile stage, citrate 
of magnesia is very satisfactory. As a rule, children like it. It may 
be given in doses of from two to four ounces, to children from two to 
five years of age. In case it is not well taken, from one to two tea- 
spoonfuls of the aromatic cascara may be given. 

Specific Medication. — There is no specific medical treatment for 
scarlet fever. Many of my cases have passed through the entire illness 
without the use of any other measures than those suggested above. 

Serum Treatment. — The value of the serum treatment has been 
by no means demonstrated, and its use is not advised. The pre- 
paration of serum and its use before we know the nature of the scarlet 
fever poison is, to say the least, premature. The only use of serum 
therapy, so far as we know at the present time, regardless of the kind 
employed, is to assist the organism in battling with the disease. 

Nursing.— As the course of scarlet fever is distinctly cyclic in 
character, much can be done in the most severe cases to prevent 



SCARLET FEVER 331 

complications, and to relieve the patient of his temporary burden. 
Since one of the most important offices we have to perform is to 
keep the vital force at the highest possible point, we must do every- 
thing in our power to preserve the natural resistance of the patient, 
and this we have done in no small degree when we have so arranged 
clothing, diet, fresh air, bowel evacuation, sleep, and quiet, as to 
insure the child's comfort and well-being. The amount of vitality 
wasted by an uncomfortable, restless child in twenty-four hours may 
turn the case from a successful to a fatal issue. 

I fully believe in " spoiling" a sick child. If a child is more at 
ease with the mother, the mother's place is with the child. If the 
mother's presence disturbs the child, as it does in some instances, 
she should be kept in the background. If it is apparent that the nurse 
selected is not to the child's liking, or not adapted to the case, another 
should be secured. I have been obliged repeatedly to take my best 
nurses from children gravely ill, because the patients were irritable 
and unhappy in their presence. 

Quiet. — Quiet is most necessary. One person in the sick-room 
with a child very ill is all that should be allowed. A second person is 
of no service, and if admitted, good air is vitiated ; moreover, it is not 
to be expected that two persons of the "female persuasion" in the same 
room will not talk! 

Indications of Severity. — The physician who has seen a few cases 
of scarlet fever can usually judge within the first three days as to the 
severity of the infection. It is indicated by the character of the rash, 
the height of the temperature, and to a lesser degree by the severity 
of the angina. A case which, on the second or third day of the rash, 
shows a temperature range from ioi° to 103° F. means that we have 
not a very severe infection and that the case probably will be mild. 

Control of Fever. — A case in which the fever rises suddenly to 
104° or 105° F. with a tendency to remain there, means that we 
have a severe infection to deal with. I find it a safe rule not to 
allow the temperature to go much above 104° F. A higher tem- 
perature than this necessitates an overworked heart. For the pur- 
pose of controlling the temperature, a fifteen-minute sponging every 
hour with water at 90° F. may be tried. 

Packs. — If sponging does not answer, the pack (page 503) should 
be brought into use. Simply because the child has a rash is no contra- 
indication to the application of moderate cold to the skin. The pack 
may be used in scarlet fever just as in pneumonia or typhoid fever. 
The fear that the disease may "strike in" and kill the patient is one 
of the many inexplicable ideas of the laity w4th no foundation in 
fact. The child is placed in the pack at 95° F. It will rarely be 
necessary to reduce the temperature of the pack below 80° F. If 
the case is of the fulminating type with persistent high temperature, 
it may gradually be reduced to 70° F. In reducing the temperature 
of the pack, the towel is not to be removed from the patient. He is 



332 CONTAGIOUS DISE^ASKS 

turned from side to side and the towel moistened with water at the 
desired temperature. Time and again I have seen children who 
were tossing about the bed delirious and sleepless, fall into a quiet 
sleep when placed in a pack. With a reduction of the temperature, 
there is a corresponding diminution in the pulse-beats of from twenty 
to thirty a minute. When we think what a saving this is to the work 
of the heart, its benefit is most apparent. 

Tub-baths. — The full tub-bath at a temperature of 95° F. for ten 
minutes at the commencement of a case in which there is a great deal 
of restlessness and irritability, will often act most satisfactorily in 
quieting the patient. Tub-bathing, however, requires a great deal 
of handling of the patient, and in the cases in which there is a 
persistent high temperature, and in those in which it mounts up 
suddenly after the bath, the pack is by far the more satisfactory. 

Oil Inunction. — The itching and burning of the skin in scarlet 
fever are most distressing. This also is relieved to a considerable 
degree by the pack. The child's comfort will also be greatly en- 
hanced by an inunction twice daily of cold-cream or liquid albolene. 
Vaselin or olive oil may be used, but they are much less satisfac- 
tory. Vaselin will act as an irritant to some sensitive skins. 

During the period of desquamation the oily applications largely 
prevent a free distribution of the scales, and thus limit the chance of 
infecting others through the clothing and other objects in the room. 

Heart Stimulants. — If, during sleep, the pulse is over 150 a min- 
ute with a weakened first sound, a heart stimulant is necessary. For 
a child one year of age, one drop of tincture of strophanthus at two- 
hour intervals, or an equal amount of the tincture of digitalis, should 
be given. On account of its being well borne by the stomach, the 
tincture of strophanthus is always preferred. Strychnin is a remedy 
of considerable value as a heart stimulant. When the pulse is soft 
and the heart action shows a tendency to irregularity, -2^0" grain may 
be given every two to four hours to a child from one to three 
years of age, and yio" grain to a child from three to six years of age, 
at intervals of from two to four hours. Alcohol should be used only 
in the septic, asthenic cases when other means of stimulation have 
failed. In such instances it should be used freely. In a few cases I 
have used it in very large quantities with striking benefit. Begin- 
ning with one-half dram of whisky every two hours, it may be in- 
creased gradually until its beneficial effects are noticed on the heart 
action. It is astonishing how much alcohol may be given, in a pro- 
foundly septic case, without the sHghtest effect, except an improve- 
ment in the heart action, and a corresponding improvement in the 
child's general condition. 

Care of Throat and Nose. — The throat and nose demand our at- 
tention during the acute stage. For the nose toilet in older children, 
a solution of menthol and liquid albolene is used by means of an 
atomizer (Fig. 35) and in the very young by instillation with a 



scarle:t fever 333 

medicine-dropper. A forcible syringing of the nose in a young child 
is not a safe procedure even in the most skilled hands. Local treat- 
ment of the throat depends entirely upon its condition. If the 
mucous membrane is swollen, edematous, and covered with a glairy 
mucopurulent secretion, or if there is a pseudo-membrane, or if there 
is much pain or discomfort upon swallowing, local treatment is re- 
quired. The child is made to gargle, if old enough, or, what is far 
better, the throat is irrigated with hot saline solution, at 120° F. 
This is done as is described on page 250. Force will be required 
in the very young. In older children, the relief from pain that is 
experienced by free irrigation is so great that usually the child takes 
the tube in its mouth gladly for the future irrigations. The use of 
antiseptic gargles and washes has not seemed to me to possess any 




Fig. 35. — The de \'ilbiss Oil Atomizer. 

value other than that of cleanliness, and free douching accomplishes 
this in a far more satisfactory manner. 

Complications. — Cervical Adenitis. — Cervical adenitis is a very 
frequent complication of scarlet fever, and when suppuration occurs 
it is a most troublesome one. With the first sign of a swollen gland, 
apply an ice-bag and keep it constantly applied day and night. 

This is a very difficult procedure in many children. When trouble 
is experienced in using the ice-bag, a cold compress (page 262), with 
water at 50° or 60° F., and changed every thirty to sixty minutes, 
will answer almost as well. Several thicknesses of old linen, such as 
furnished by a table napkin, answers well as a medium for applying 
the cold. The material used should be cut of sufficient length to extend 
from ear to ear under the jaw. In order that the moisture be retained, 
oiled silk or rubber tissue may be placed over the dressing, and over 
all a thin gauze bandage, which is pinned together on top of the head. 



334 CONTAGIOUS DISEASKS 

When either of the above is not practicable, apply 30 percent 
ichthyol in zinc ointment, which is kept bound on the parts, the appli- 
cation being renewed every three hours. Cataplasma kaolini may 
also be used. It is spread on a piece of linen and applied over the 
swollen area. It should be renewed at six-hour intervals. Whether 
the ice-bag, the ichthyol, or the emplastrum kaolini is used, Crede's 
ointment may be given a trial, ten grains being rubbed into the skin 
over the swollen gland for fifteen minutes twice daily. 

Otitis.— Otitis is a complication in 10 to 30 percent of the cases 
of scarlet fever. In view of the grave possibilities of mastoid 
involvement, sinus thrombosis, and jugular bulb infection, the pres- 
ence of pus in the middle ear should be promptly detected, and the 
pus evacuated by a free incision of the drum membrane. The pres- 
ence of middle-ear infection may be suggested by a pain or a sensa- 
tion of fullness in those old enough to locate it. In infants, restless- 
ness, sleeplessness, or tenderness on manipulation in cleansing the 
ears may be the only objective signs of the trouble. In the majority 
of my cases of otitis, none of the above signs of pain and discomfort 
were present. The ear involvement was suggested because of a contin- 
ued elevation of temperature which could not otherwise be accounted 
for. With a persistent elevation of the temperature of unknown 
origin following scarlet fever, the ears should be examined by an ex- 
pert in otoscopy. As a routine measure during the fever, the condi- 
tion of the drum membrane should be noted at least every second day. 

As stated above, otitis develops in from 10 to 30 percent of the 
cases, depending somewhat upon the character of the epidemic, but 
more upon the age of the patient. The younger the child, the 
greater the danger of ear involvement. Many cases of deafness 
which we meet had their origin in an attack of scarlet fever, and are 
due to somebody's ignorance or neglect. Among 185 cases of scarlat- 
inal otitis, reported by Bezold and quoted by Holt, in 30 there was 
entire destruction of the membrana tympani; in 59, the perforation 
comprised two-thirds or more of the membrane; in 13, there were 
small perforations; in 44, there were granulations or polypi; in 15, 
there was total loss of hearing on one side, and in 6 of the cases upon 
both sides; in 77, the hearing distance for low voice was less than 
twenty feet. May, of New York, has collected statistics of 5613 
deaf-mutes, of whom 572 owed their condition to otitis following 
scarlet fever. When we consider how many cases of permanent ear 
defects have occurred and do occur every year as a result of careless- 
ness or lack of even an elementary knowledge of aural diagnosis, we 
do not feel inclined to congratulate the members of the medical pro- 
fession as to their ability to complete their cases. The bacteriology 
of scarlatinal otitis is the same as in suppurative otitis developing 
with or following any other infectious disease, except that there is a 
greater tendency to severity because of the liability to streptococcus 
infection. Prompt relief demands prompt recognition of the con- 



SCARLET FEVER 335 

dition of the drum membrane, with evacuation of the pus and suitable 
after-treatment. (See Acute Suppurative Otitis, page 442). This 
will not be possible if the practitioner does not examine the ears or is 
not sufficiently expert to recognize a diseased condition when he sees it. 

Cardiac Invohement. — Heart complications are not particularly 
frequent in scarlet fever. Nevertheless the heart should be examined 
daily. In my own observations, they have been present in about 2 per- 
cent of the cases. The treatment of peri-endo and myocarditis is 
laid down elsewhere under appropriate headings. 

Nephritis. — Early in the cases of severe infection there will often be 
discovered a transient albuminuria with a few hyaline casts. There 
may be slight suppression of the urine. In but one of my cases was 
there complete anuria at this stage of the disease. Within thirty-six 
hours after the first sign of the disease, the kidneys ceased to act, and 
the child died on the third day, from the acute diffuse nephritis. The 
condition of the kidney giving rise to albuminuria is best reheved by 
attention to the skin function by the use of a bath at a temperature 
of 105° F. every six or eight hours. The child may remain in the 
bath for ten minutes, during which time the skin should be vigorously 
rubbed with the bare hand. The tincture of aconite in doses of one 
drop, with five drops of sweet spirits of niter every three hours, for a 
child eighteen months of age, will usually produce a satisfactory 
skin action. 

What is known as scarlatinal nephritis rarely appears before the 
third week of the disease. I have known cases to occur as late as the 
sixth week. The management of this complication will be found on 

page 357. 

Arthritis as a complication of scarlet fever is seen in only a few of 
the cases — about 3 percent. There may be swelling or redness of the 
parts, or both these symptoms may be absent. Whether the swelling 
is present or not, the joints are very painful on manipulation. Affected 
joints should be wrapped in old linen, saturated with a lead and 
opium solution, and the dressing renewed every six hours. The fol- 
lowing lotion has answered well in a few cases : 

I^. Mentholis oij 

Tincturae opii iv 

Spiriti vini recti q. s. ad 3 vj 

Soft linen is moistened with the lotion and wrapped about the parts 
and covered with oiled silk or rubber tissue. The part affected is then 
wrapped in flannel or cotton-wool. The lotion may be freshly applied 
at intervals of from four to six hours. The only objection to its use 
is the odor of the menthol. Internally, to a child four years of age, 
aspirin may be given in doses of five grains, with ten grains of the 
bicarbonate of soda at four-hour intervals, four doses being given in 
the twenty-four hours and continued until the arthritis is relieved. 
Salicylate of soda may be used in smaller doses, three to four grains; 
but, as it may be badly borne by the stomach, aspirin is preferable. 



336 CONTAGIOUS DISEASES 



WHOOPING-COUGH— PERTUSSIS 

As an infectious disease of importance, pertussis may be classed 
with diphtheria and scarlet fever. It is probably the cause of more 
deaths today than is any other infectious disease. It does not kill 
directly through the means of a specific poison, as do diphtheria and 
scarlatina; but, on account of its prolonged course and its many 
complications, it is equally effective as a life-destroyer. 

Susceptibility. — That pertussis is one of the most infectious of dis- 
eases is well illustrated by the following history : On a bright cold day 
in December a patient of mine, nine months of age, passed in its car- 
riage on the street a child of about the same age who had pertussis. 
This child was also in its carriage. My patient took the disease. There 
was no other possible source of infection. That pertussis may be 
conveyed through the medium of the clothing of a second person is 
exceedingly doubtful. Direct exposure seems necessary for infection 
to take place. The period of infection dates from the beginning of the 
catarrhal stage, and lasts for two or three weeks from the cessation of the 
paroxysms. The period of incubation is from seven to fourteen days. 

When pertussis breaks out in a school or in an institution for 
children, it is practically impossible to prevent an epidemic. This 
is because the disease is infectious during the early catarrhal stage, 
which lasts from one to two weeks. During this time the only symp- 
tom is a cough, and perhaps a slight degree of bronchitis, such as we 
meet in a common cold. 

The previous state of health appears to exert no influence as far 
as the susceptibility is concerned. The strong and the delicate are 
alike predisposed to infection. The very young and the adult are 
less liable to take the disease. From the fourth month to the third 
year is the most susceptible time of life. Cases have been reported 
in children one week old. Any other concurrent infectious disease 
exerts no influence upon the course of the pertussis. It has been 
claimed that the advent of diphtheria or scarlet fever during an 
attack of pertussis shortened and modified the course of the per- 
tussis. My experience does not corroborate this statement. Other 
affections, which may develop during an attack, simply increase the 
burden to be borne by the patient. The largest number of cases de- 
velop during the warmer months, from May to November. This 
may be accounted for in part by the fact that at this period of the year 
the infected child comes more frequently in contact with its unpro- 
tected neighbor. It tends to disprove, however, that catarrhal affec- 
tions of the respiratory tract predispose to the disease, as respiratory 
affections in the young during the warmer months are notably rare. 
The normal mucous membrane of the healthy offers no greater re- 
sistance than does the diseased structure of the ailing. We have, in 
the early stages of pertussis, not simply a bronchitis, as has been 
claimed, but a catarrhal process due to a specific infection. 



WHOOPING-COUGH — PERTUSSIS 337 

Interesting observations relative to susceptibility to measles and 
pertussis were made by Biedert. After an absence of sixteen years, 
both these diseases broke out in a German village about the same 
time. There were 401 children in the village under fourteen years 
of age. These children had never been far from home, and not ona 
of them had had either measles or pertussis. Of this number, 344 
came down with measles and 366 with pertussis, 340 having both 
diseases at once. 

The susceptibility of these unprotected children to pertussis w^as, 
therefore, 95.5 percent; to measles, 85.8 percent. The ages of those 
who escaped pertussis were as follows: Seven were under five 3^ears 
of age ; four between five and ten years ; nine between ten and four- 
teen years. 

Complications. — The complications of pertussis are many, and it 
is through them that the disease is so destructive to life. The mor- 
tality of pertussis is generally estimated at from 4 to 6 percent. 
That it is actually much higher than this is well known to every one 
who has seen much of the disease. The most fatal complication is, 
in winter, bronchopneumonia, and, in summer, gastro-enteric disease. 
Convulsions are not an infrequent complication and may be fatal. 
Malnutrition often follow^s a severe attack in the deUcate bottle-fed 
children, thus paving the w^ay for intercurrent disease. Tuberculosis 
not infrequently follows a prolonged attack of pertussis. Blindness, 
deafness, and motor disturbances have all been obser\''ed during attacks 
of pertussis, which resulted in complete recovery. These cases may 
be explained as follows: During a severe paroxysm the cerebral cir- 
culation is greatly disturbed, resulting in a moderate congestion or 
venous hyperemia, which produces a disturbance of nutrition in 
certain portions of the brain. With the return to the normal, these 
symptoms all disappear. 

Diagnosis. — The diagnosis of pertussis is most difficult in the 
early stages, before the whoop or the convulsive nature of the 
paroxysm develops. Even a spasmodic cough does not always mean 
that we have a developing pertussis. The cough, if more troublesome 
at night, favors a diagnosis of pertussis. Further, if we have a 
pertussis to deal with, the cough grows steadily worse, and resists all 
the usual methods of treatment, the whoop soon establishing the 
diagnosis. In rachitic children, and in those in whom the nervous 
element is prominent, the cough of an ordinary cold is often of a de- 
cidedly paroxysmal character, especially when there is an acute or 
subacute laryngitis. The mild cases are also difficult of diagnosis. 

Illustrative Cases. — Recently tw*o patients, aged eight and ten 
years respectively, went through an attack of pertussis wdth but two 
or three severe paroxysmal coughing attacks. Two other cases seen 
in private practice show also how mild the course may be : The pa- 
tients, brother and sister, aged six and eight years respectively, 



338 CONTAGIOUS DISKASKS 

commenced coughing about ten days after exposure. The cough 
was paroxysmal, with from three to five seiziires in twenty-four 
hours. The boy whooped only three times during the entire course 
of the disease ; the girl never whooped at all. Vomiting never oc- 
curred with a paroxysm. Both coughed six weeks. These children 
had neither adenoids nor bronchitis. 

Often the very young and the very delicate do not whoop even 
during a severe attack. Among the severe cases, convulsions and 
hemorrhage from the nose, ears, and eyes, were seen from time to 
time. A very severe seizure in a girl nine months old was followed 
by small extravasations of blood into the skin of the entire body. 

In all cases of severe cough of uncertain origin, the nasopharyngeal 
vault must always be examined for adenoid growths. This, in young 
children, can properly be done only by the use of the index-finger. 

Pertussis in children under eighteen months of age must ever be 
regarded in a serious light. Delicate and rachitic children should be 
carefully guarded against the disease. Bronchopneumonia and 
gastro-enteric troubles are the most frequent complications among 
this class of children. The majority of healthy children over eighteen 
months of age bear an attack without any great inconvenience. 

Treatment. — In considering the management of pertussis we are 
first to remember that the disease is self -limited, that it cannot be 
cured by treatment, and that, in commxon with the other infectious 
diseases, all we can do is to make it as easy as possible for the pa- 
tient to bear. We cannot shorten the attack, but we can lessen the 
number and severity of the paroxysms. This is to be accomplished 
by the use of drugs administered by the mouth. The rubbing of a 
few drops of Roache's embrocation on the stomach is, of course, 
valueless. The believers in the theory that the chief seat of trouble 
is in the nose, have advocated and brought into use the insufflation 
of various kinds of powders, prominent among which are boric acid, 
resorcin, and ground coffee. This treatment, as might be expected, 
is of no service. 

During a three years' epidemic of whooping-cough in the 
Country Branch of the New York Infant Asylum, from sixty to 
ninety children were constantly in quarantine. New cases developed 
about as rapidly as the old ones were discharged. During the epi- 
demic children were quarantined who did not have the disease. On 
the other hand, an early diagnosis was frequently made before the 
onset of the spasmodic stage, by excluding all possible causative fac- 
tors, such as pharyngitis, laryngitis, and bronchitis. 

The cases as they developed were divided into groups of twenty. 
They were allowed to cough untreated until the height of the par- 
oxysmal stage was reached. This usually required from ten to four- 
teen days from the commencement of the cough. Careful record 
was kept day and night of the number and severity of the paroxysms. 
When there was no increase either in number or severity for three 



WHOOPING-COUGH — PERTUSSIS 339 

days, we believed the height of the paroxysmal stage had been 
reached, and the drug selected was brought into use. The ages of the 
cases treated varied from six weeks to twenty-six 3^ears. Only three 
patients had reached adult life. Five- sixths of the patients were 
under four years of age. One-half were under two years. The dura- 
tion of the attacks ranged from three to twenty weeks. From six to 
eight weeks was the usual duration. In several the attacks were so 
mild that a diagnosis was difficult. 

Drugs. — The drug treatment consisted in insufflations, internal 
administration, and inhalations. The treatment in which drugs did 
not enter was in the use of the steam spray and fresh air. Resorcin 
and boric acid combined with bicarbonate of soda were used by means 
of insufflations in six test institution-cases, and discontinued after 
three days. The treatment was found impracticable and useless. 
Inhalations of vapo-cresolene were used in ten other institution-cases. 
Apparently it had no effect whatever in modifying the disease. In 
private practice vapo-cresolene has sometimes a decided sedative 
influence upon the disturbed nervous state of the parents and does 
not harm the child! It has been used with my permission in many 
private cases. Medicated steam inhalations, creosote, turpentine, 
and wine of ipecac were used in many cases with decidedly beneficial 
results. The cases selected for the inhalations were those of the 
very young and delicate, wdth a complicating bronchitis, the steam 
being used in connection with other treatment. The drugs selected 
for internal administration were alum, fluidextract of horse-chestnut 
leaves, dilute nitric acid, hydrochlorate of cocain, bromoform, quinin, 
the bromids, belladonna, and antipyrin. 

The fluidextract of horse-chestnut leaves and dilute nitric acid 
were each used in twenty test institution-cases. After a trial of 
five days they proved valueless, or objectionable on account of the 
vomiting produced, and were then discontinued. Alum appeared to 
be of some service, but it was badly borne by the stomach. Bromo- 
form was used in sixteen dispensary and in six private patients. In 
three only did it appear to be of service. 

One-tenth grain of hydrochlorate of cocain every four hours for a 
child two years of age was employed in twenty-three dispensary and 
in five private cases. It possesses some value in controlling the 
severity of the paroxysms, but the results were not sufficiently 
marked to warrant its further use. 

Quinin has been used in a large number of cases, in both private 
and out-patient work. I find that great benefit may be derived from 
its use if a large amount can be given. Its administration, however, 
is attended with difficulties. Twelve to twenty grains in twenty- 
four hours are required for pronounced results in children from two 
to six years of age. The administration of such a large amount of 
this well-known drug is not favorabty received by many parents. 
Our inability to make it palatable is a serious drawback at any age. 



340 CONTAGIOUS DISEASES 

and almost excludes its use in the very young ; furthermore, in the very 
young and delicate it is apt to derange the stomach and produce 
vomiting. If given in solution it is best to use the bisulphate in 
yerberzine (Lilly). In older children, when quinin can be given in 
sufficient quantities in capsules, the improvement as to the number 
and severity of the paroxysms is sometimes surprising. 

Belladonna was used in sixty test institution-cases. It was be- 
gun at the height of the paroxysmal stage. It was administered to 
the point of physiologic effect for a period of from five to seven days 
without influencing a single case of whooping-cough in the slightest 
degree. True, the cases were all severe, but they responded promptly 
to other means used later. The children were all between three and 
seven years of age. I have repeatedly seen these children with 
dilated pupils and the characteristic belladonna blush, grasping a 
crib or a chair for support during a paroxysm that furnished an ideal 
clinical picture of the disease. 

Equal quantities of the bromids of sodium, ammonium, and po- 
tassium were used in sixty test institution-cases. The results, con- 
sidered from all standpoints, were better than with any of the means 
of treatment thus far referred to. The severity and duration of the 
paroxysms were especially influenced, although the number of 
seizures was practically unchanged. From twelve to sixteen grains 
in twenty-four hours were given to a child one year of age. When 
given in syrup of raspberry on a full stomach, or with plenty of water, 
there is very little disturbance attending its use. For a child two 
years of age, sixteen to twenty-four grains may be given daily. 

Antipyrin was used later in sixty test cases in the institution, as 
well as in out-patients and in private work. I have given antipyrin, 
combined with bromid of soda, in over six hundred cases of pertussis. 
The antipyrin was given under the same conditions as those already 
referred to, combined with syrup of raspberry. 

I^. Antipyrinae gr. xviij 

Sodii bromidi gr. xxx 

Syr. rubi idaei 5 v 

Aquae q. s. ad 5 ij 

M. Sig. — One teaspoonful every two hours, six doses in twenty- 
four hours, for a child fifteen months of age. 

Antipyrin is readily taken and easily borne by the stomach — two very 
desirable requirements in a drug that is to be given to a child for a 
considerable time. It is not depressing when given with any degree 
of intelligence — in fact, it is well borne by children when given in good- 
sized doses, and it controls whooping-cough better than does any 
other drug I have ever used. Its beneficial effects are as follows: 
The paroxysms are diminished in number from one-third to one-half 
without any amehoration of an individual seizure, or the seizures may 
be less severe without any diminution in their number. In some, 
both the severity and the number of the paroxysms were favorably 
influenced. In all the cases the effect of the drug was beneficial. 



WHOOPING-COUGH — PERTUSSIS 34 1 

Antipyrin gave the best results of any drug used alone. The 
bromids took the second place. We then combined the two and used 
them in forty institution-cases. We soon learned that the two drugs 
given together more effectively controlled the disease than when 
either was given separately. In combination they gave satisfaction 
in the large number of cases previously referred to. At the out- 
patient department of the Babies' Hospital we use the drugs com- 
bined in the form of a compressed tablet. For a child eight months 
of age one-half grain of antipyrin with two grains of bromid of soda 
are given at two-hour intervals — six doses in twenty-four hours ; for 
a child of fifteen months, one grain of antipyrin and two and one- 
half grains of bromid of soda at two-hour intervals — six doses in 
twenty-four hours; from the fourth to the eighth year, two grains 
of antipyrin and five grains of bromid of soda at two-hour inter- 
vals — six doses in twenty-four hours. 

Codein is used only in the most severe forms of pertussis, when 
other means fail to relieve the patient. One of the most troublesome 
features of the disease, in fact, a dangerous feature, is the wakefulness 
at night caused by repeated attacks of coughing and vomiting. When 
the child cannot sleep, I give codein independent of the other treat- 
ment, whatever it may be. For a patient five years of age, one- 
sixth grain is given at bedtime and repeated during the night when- 
ever the paroxysms require it. For a child from eight to twelve years 
of age, one-fifth grain may be given at bedtime and repeated twice if 
necessary. For a child from two to three years of age, one-tenth grain 
may be given and repeated not oftener than twice during the night. 
The drug should not be continued longer than a week or ten days. I 
have never seen unpleasant effects follow its use. 

It will be observed that the drugs of value in whooping-cough are 
the sedatives. It is well known that by the prolonged use of seda- 
tives their effect is lost. For this reason I have found it wise to use 
what may be called ' ' interrupted medication. ' ' For five days the anti- 
pyrin and bromid of soda are given, then stopped, and full doses of 
quinin are given for five days, when the antipyrin and bromid are 
resumed. In this way, giving the drugs five days each, we continue 
with advantage for a month or six weeks. It is rarely necessary to 
continue the treatment longer than six weeks ; usually from three to 
four weeks is sufficient. Of course, the child will whoop after that 
time, but the active stage of vomiting and severe paroxysms will be 
over. If the vomiting can be controlled in an attack of pertussis, 
and if the patient can obtain sufficient sleep, much has been accom- 
plished. I would emphasize here, what has already been suggested: 
Do not begin the specific whooping-cough treatment, whether by the 
administration of quinin, antipyrin, or other remedies, until the spas- 
modic stage is at its height. If a sedative is given as soon as a diag- 
nosis is made, by the time the disease reaches its height tolerance will 
have become so established that the drug will have lost not a little of 



342 



CONTAGIOUS DISEASES 



its sedative action. If medicines must be given during the earliest 
stage, a placebo may be used. The Infant Asylum patients, upon 
whom the best of our observations were made, received distilled 
water colored with compound tincture of cardamom. 

Steam inhalation is referred to only to call attention to its value 
when used in connection with the drug treatment. It has been 
of great service in the very young, and among those who have 
compHcating bronchitis and bronchopneumonia. I prefer the 
Arnold steam atomizer (Fig. 36). The nozzle is placed about eight 
inches from the face, which alone is exposed, the other parts of the 
body being well protected by a rubber sheet. The inhalations, when 
taken from fifteen to twenty minutes every two hours, often give 
a weakly, cyanosed patient marked relief. I have used wine of ipecac, 
creosote, and turpentine in the vvater thus vaporized, as mentioned 

before; but I am not convinced 
that they offer any advantage 
over plain steam. 

Fresh air is of immense value 
as a means of relief in whooping- 
cough. We are told that the 
child rarely coughs when out of 
doors, but commences as soon 
as he is brought into the house, 
which is usually overheated and 
badly ventilated. In nearly all 
cases the cough is worse at night. 
This may be explained in part 
by the absence of proper ventila- 
tion in the sleeping apartment. 
Many out-patient mothers tell 
me that remaining for hours 
with the child near a gas tank relieves the whooping-cough, and it 
doubtless does. There is a vast difference between the comparatively 
pure air in the vicinity of the gas tank and the air of the average tene- 
ment. I always encourage the gas-tank treatment. A child who for 
any reason must remain indoors should not be allowed to remain con- 
stantly in one room. There should be two rooms, every window in 
the one not in use being freely open. The living-room and sleeping- 
room should be kept at a fairly even temperature — from 68° to 70° F. 
The Kilmer Belt. — A few years ago Dr. T. W. Kilmer, of New- 
York, conceived the idea that a belt around the child's body producing 
firm pressure, would support the abdomen sufficiently during a 
coughing paroxysm to prevent vomiting. The Kilmer belt (Figs. 37 
and 38) was the outcome. I have used the belt in a considerable 
number of cases; at first with a great deal of skepticism, watching 
the patients upon whom it was used at my clinics at the out-patient 
•department at the Babies' Hospital and at the New York Polyclinic, 




Fig. 36.— The Arnold Steam Atomizer. 



WHOOPING-COUGH — PERTUSSIS 



343 



where records were kept of the number of vomiting seizures in twenty- 
four hours, for three days before applying the belt, and the further 
record after the belt was in use, together with the statement of the 
mothers and oftentimes of the children themselves. These records 
convinced me that the belt has a field of usefulness in the management 
of whooping-cough. I later adopted it for use among my private pa- 
tients. Like most remedial measures, however, its use is not always 
attended with success. I have applied the belts without the slightest 
benefit in some vomiting cases. Usuall}', how- 
ever, it is of service in relieving the vomiting. 
In some the vomiting has entirely ceased after 
the belt was applied. I believe it should be 
given a trial in every severe case, particularly 
where the vomiting is a very prominent symp- 





Fig. 37.— The Kilmer 
Belt. 



Fig. 38.— The Kilmer Belt in Position. 



tom, and in infants in whom the drug treatment is unsatisfactory. 
The belt,^ which has been improved from time to time, is made of 
linen, with pieces of rubber elastic at those portions which rest against 
the sides of the child. There are eyelets in each end for the purpose 
of lacing the belt together. It is best to, apply it over the nether- 
most garment. 

^The belt is made by J. Jungmann, New York. In taking a measurement 
the circumference of the abdomen around the most prominent parts should be 
taken. This with the age of the child should be sent to the manufacturer. 



344 CONTAGIOUS DISKASKS 



MEASLES 

Measles is a disease which few of the human race escape. In itself 
it cannot be considered a dangerous disease, for when uncomplicated, 
it is almost never fatal. On account of its tendency to respiratory 
complications, however, particularly in the young and the feeble, it is 
indirectly one of the most fatal diseases. During the year 1906, 441 
deaths due to measles occurred in Greater New York — 58 more than 
were caused by scarlet fever. 

Popular Misconceptions. — Grave errors exist among the laity, 
and perhaps among a few physicians also, as to the proper manage- 
ment of the more severe exanthematous diseases, and as the measles 
patients suffer most from this failure properly to appreciate existing 
conditions, it is not out of place to speak of them here. 

The popular conception as to the management of measles is that 
the patient should be warmly wrapped, given hot drinks, and kept 
in a dark room with little or no ventilation. An attack of measles 
renders the child, for the time being, a very susceptible subject for 
bronchopneumonia. The younger or the more delicate the child, 
the greater the danger. The dark room with its closed windows and 
doors and dust, the extra wrappings with the resulting heat "consti- 
pation," and the reduced vitality, do much to prepare the way for 
that which we most dread in an attack of measles, viz., a possible 
bronchopneumonia ; for in measles one danger-signal is up constantly 
throughout the attack, and it always reads pneumonia. 

Complications. — In children's institutions today measles is dreaded 
more than diphtheria and more than scarlet fever, for the reason that 
when an epidemic breaks out, because of its marked early contagious 
characteristics, it means, in all probability, many cases and many 
deaths. In an epidemic in one of the New York institutions for chil- 
dren, a few years ago, there was a death-rate of 40 percent from 
measles complicated with bronchopneumonia. Having been through 
many epidemics of measles in children's institutions, and having seen 
many cases in private and complicated cases in consultation, I am 
convinced that in this disease we have an illness which should inspire 
much greater respect on the part of the physician and demand the 
highest intelligence on the part of both physician and the family in 
order that it be managed to the be'st interest of the patient. Sup- 
purative otitis is a fairly frequent complication ; nephritis is a rare 
one. 

PneumxOnia is an infectious disease. In measles an inflammation 
of the mucous membrane of the respiratory tract is a part of the dis- 
ease. We have thus prepared for us a most favorable soil for the 
development of pathogenic bacteria that may be inhaled through the 
mouth or nose. Given a dust-free room, advisedly ventilated, and 
we would have comparatively few cases of measles-pneumonia. 



MEASLES 345 

Treatment. — General. — A child ill with measles should be com- 
fortably clad in the usual night-clothes and kept in bed. No extra 
wraps are required ; neither is it desirable to keep the room at a higher 
temperature than is customary; 68° to 70° F. is a suitable room 
temperature. There are many gradations of light between glaring 
simhght and utter darkness. Both are extreme, and one almost as 
undesirable as the other. It is my custom to advise that a window- 
shade of dark green be lowered within one foot of the window-sill. 
The hght brown or drab shade should be lowered completelv. If 
the shade is white or a very Hght color and not protected by a 
curtain of dark material, it will be necessary to exclude the bright 
light by some other means. 

The patient should be put on a greatly reduced diet. If bottle-fed, 
the milk mixture should be diluted at least one-half by adding boiled 
water, the same quantity being given as in health. In fact, the appe- 
tite in the early stage of measles is practically absent, so that little or 
no food is taken. Patients with measles are given water to drink freely 
at a temperature not lower than 50° F. For " runabout" children, 
eighteen months of age and over, the diet as suggested for the sick 
(see page 139) should be given. 

There should be one evacuation of the bowels daily. An enema 
should be given when this does not otherwise take place. The urine 
should be examined for albumin every second day. 

During the waking hours the eyes should be generously bathed 
every hour or two with a 3 percent solution of boric acid, using old 
linen or cotton, which is afterward destroyed. 

Symptomatic. — ^The temperature of uncomplicated measles is 
rarely high enough to call for special interference. If it should have 
a tendency to continue above 104° F. for eight or ten hours and the 
child be uncomfortable and restless, a tepid sponge-bath may be 
given, the duration of which may be from ten to twenty minutes, 
and repeated at intervals of tw^o or three hours. Whether the fever 
demands it or not, the patient should be sponged twice a day with 
tepid water at 100° F. He is then dried and an application of 
cold-cream, liquid albolene, or olive oil is made to the entire body. 
This is given for the sole reason that it relieves the itching, induces 
sleep, aids digestion, reduces the temperature, and enables the child 
to pass through the disease with less discomfort. 

Now and then a case is encountered in which the rash is slow in 
appearing. The temperature is high, 104° to 105° F., the skin hot 
and dry, and the child very uncomfortable, perhaps delirious. In 
such patients a hot bath, 105° F. to 110° F., of from three to five 
minutes' duration will often bring out the rash, greatly to the relief 
of the symptoms, which may have been of an urgent character. 

The cough of measles during the active period of the attack is one 
of the annoying features of the disease, and some relief must be 



346 CONTAGIOUS DISEASKS 

attempted, particularly if the child is kept awake at night by it. 
The ordinary expectorants alone are of no service in a measles cough. 
A sedative only will give relief. For a child six months of age, from 
five to eight drops of paregoric may be given, and repeated after an 
interval of two hours, if necessary. The following combination of 
paregoric and sweet spirits of niter is often of service : 

I^. Tincturae opii camphoratae gtt. x 

Spirit! etheris nitrosi gtt. iij 

M. Sig. — One dose ; to be repeated every two or three hours, for 
a child of eighteen months or older. 

From the first to the second year ten to fifteen drops of paregoric 
may be given at two-hour intervals, if required, or one-half grain of 
Dover's powder may be used. Usually, it will be necessary to give 
but two or three doses of the sedative during the night. Should the 
paregoric or Dover's powder be objectionable because one may dislike 
to give opium to young children, from three to four grains of sodium 
bromid in two drams of water, repeated as required every hour or 
two, will be of service for a child under two years of age. From the 
second to the fifth year one grain of Dover's powder, or from fifteen 
to twenty-five drops of paregoric, or yV to J grain of codein, may be 
given at intervals of from two to four hours. 

If bronchitis develops sufficiently to require treatment, as it does 
in at least one-half the cases, the means for the management of bron- 
chitis suggested on page 271 will be found useful. The temperature 
of a child ill with measles should be taken three times daily and the 
lungs and heart should be examined every day. It is my custom to 
keep the air of the sick-room moistened with vapor during the entire 
illness. Its benefits are twofold. It relieves the cough, as it is more 
agreeable to the congested mucous surface during the early stage, and 
prevents the free circulation of dust, the danger of which has already 
been referred to. If the room is carpeted, it should be well sprinkled 
with water before sweeping. It is much better if the floor is bare, as 
the broom can then be dispensed with and a damp cloth used instead. 
The length of the quarantine is usually from twelve to sixteen days, 
at least ten days of this time being spent in bed. 

Otoscopic examination should be made every second day until 
the case is discharged. In the event of a sudden rise in tempera- 
ture during convalescence, which cannot be explained by the con- 
dition of the intestines, lungs, or throat, such an examination should 
be made by an expert. 

CHICKEN-POX— VARICELLA 

Chicken-pox is a disease for which very little treatment is re- 
quired. During the eruptive period and until the stage of vesicula- 
tion is passed and crusts have formed, it is well to keep the young 
child in bed. Older children will find such confinement irksome, 



GERMAN MEASLES — RUBELLA 347 

and they may be allowed to be about the room, but should not be 
allowed to go out of doors. During an attack of chicken-pox the 
child is more sensitive to exposure, and while compHcations, such as 
nephritis, are rare, one of the worst cases of acute nephritis which it 
has been my lot to treat developed as a sequela of chicken-pox. 
The itching is the most annoying feature of the disease, as it causes 
restlessness, loss of sleep, and, through the child's attempts at secur- 
ing relief by scratching, opens up the possibility of grave skin in- 
fections. In out-patient work I have repeatedly seen extensive 
furunculosis follow an attack of chicken-pox. In two institution- 
cases erysipelas developed, and in two others dermatitis gangrenosa 
was a sequela. During the stage of active eruption the child should 
not be given a tub-bath, gentle sponging with a tepid solution of 
boric acid — two heaping tablespoonfuls of boric acid to one-half 
gallon of boiled water — answering the purpose of cleanliness for a 
few days. After the daily sponging, and several times during the day, 
th-e areas affected are anointed with a lo percent boric acid oint- 
ment, made with cold-cream as follows: 

I^. Pulveris acidi borici gr. c 

Unguenti aquae rosae q. s. ad oij 

The boric acid ointment relieves the itching to a marked degree 
and doubtless is of value in preventing local skin infection. An 
equally effective remedy, but one less agreeable for domestic use, is a 
lotion composed of 5 percent ichthyol and sterilized olive oil. This 
is applied to the entire body twice daily after the bath. Objections 
to its use are the odor and the staining of the clothing and bed-linen. 
Permanent scars at the site of the vesicles are so rarely seen that no 
special precautions are required on this account. The duration of 
the attack, from the beginning of the period of eruption until the 
crusts fall, is usually about three weeks. The child should be con- 
sidered in quarantine and not allowed to come in contact with the 
unprotected, until the skin is clear. 

GERMAN MEASLES— RUBELLA 
German measles requires ordinarily very little treatment. About 
two days in bed, a few more days in the house with a reduced diet, 
and free bowel action, is usually all that is needed, recovery being 
complete in from six to eight days from the beginning of the attack. 
The enlargement of the post-cervical glands and the associated pain 
may be relieved by applications of a 2 5 percent ichthyol ointment on 
strips of linen firmly held in position. The emplastrum kaolini 
may also be used in the same manner with equally beneficial re- 
sults. Where either is used, the dressing should be changed every six 
hours. 



348 CONTAGIOUS DISE:ASES 



MUMPS; EPIDEMIC PAROTITIS 

Mumps is a contagious disease of the "runabout" age of child- 
hood. The seat of the operation of the infection is the parotid gland. 
One or both glands may be involved. Often the involvement of one 
gland is three or four days in advance of the other. The period of 
incubation is a long one — usually from two to three weeks. The 
duration of the disease, from the commencement of the swelling until 
it has completely subsided, is about ten days. It is rarely longer 
than this when both glands are involved at the same time. 

Treatment. — During an attack the child should be kept in bed 
until the temperature is normal. He should remain in the house 
until the swelling has entirely subsided. He should be put on a 
reduced diet of broths, gruels, and milk, as in any illness with 
fever. Fruits and acids should not be given because of the discom- 
fort they occasion to the patient. The bowels should move once 
daily. When this does not occur, citrate of magnesia or a Seidlitz 
powder should be given. 

The temperature rarely requires interference. If it reaches 104^ 
F., twenty minutes' sponging with one-fourth alcohol and three- 
fourths water at 80° F. will usually control it. ReUef of the pain 
and tension, which are most severe in some cases, is best secured by 
warm wet dressings. A table napkin wrung out of water at a temper- 
ature of from 110° to 120° F., and placed over the parts, is a conve- 
nient method. The warmth and moisture will be better retained if 
oiled silk or rubber tissue is placed over the dressing. The applica- 
tion should be changed every twenty or thirty minutes. During the 
night or at other times when the frequent changing would disturb 
the patient warm camphorated oil on a piece of flannel which is 
bound to the parts will usually be agreeable to the patient. 

Complications. — Complications in mumps are rare. Orchitis is 
occasionally seen in boys, and ovaritis in girls, but it rarely occurs if 
the patient is kept in bed. Infection of the parotid gland, other 
than that of the specific poison, is extremely rare. I have never 
seen a case of so-called mixed infection. Nephritis is a rare com- 
plication in mumps. I have seen one case of this nature. 

Errors in Diagnosis. — Errors in the diagnosis of mumps occur 
very frequently. A great many cases of acute adenitis are diag- 
nosed as mumps. When getting the history of the previous illnesses 
in out-patient or private work, we are not infrequently told that 
the child has had two or three attacks of mumps, which means 
that he may have had one attack, the other supposed attacks 
being acute adenitis. It has occurred to me that probably some of 
these cases which were diagnosed as mumps were due to an infection 
which had extended to the parotid from the adjacent lymph-glands. 



THE URINE 

Tables dealing with the frequency of urination and the specific 
gravity of the urine for the different ages of childhood are neces- 
sarily inaccurate, particularly when they refer to children under one 
year of age. 

Urinary Observations. — At the New York Infant Asylum a few 
years ago, Dr. George T. Myers, at that time resident physician, made 
a series of investigations under my direction as to the various phases 
and functions of the newly born infant which differed from some of 
the observations previously recorded. Among other observations was 
one as to the time of the first micturition after birth. Forty-five 
cases cover the series. It was found that the time varied greatly. 
In fifteen it occurred simultaneously with birth; in ten, in less 
than four hours ; in eight, in from four to eight hours ; while the re- 
mainder ranged between eight and eighteen hours after birth. In 
but two cases was it longer than fourteen hours. Without going 
into detail as to other studies made of the urine in young children, it 
was found that the specific gravity, the frequency of urination, and 
the amount of urine passed were subject to wide variations within 
normal limits. These various features depended upon whether the 
child was breast-fed or bottle-fed, whether it was a girl or a boy, and 
whether, if breast-fed, the mother had a scanty or a free flow of 
milk. The bottle-fed always passed more urine than the breast-fed. 
The quantity of urine is also influenced by the clothing worn and by 
the season of the year. 

Normal Variations. — Normal variations are therefore necessarily 
within very wide limits. One child will pass its urine every thirty 
minutes when awake ; others, of equal health and age, will retain it 
for three hours. Before the child takes much fluid, particularly in 
the first days of life, from two to five ounces is probably passed in 
twenty-four hours with a specific gravity of 1.005 "to i.oio. Infants 
urinating very frequently are apt to develop into bed-wetters in later 
life, probabty owing to the undeveloped condition of the bladder, the 
size of that viscus remaining small. Other than this, very frequent 
urination with an absence of signs of illness is of no significance in the 
young. After the feeding is established, the specific gravity will 
range from 1.003 "to 1.012 from the second week to the second year. 
A baby nine months old will pass an average of about twelve ounces 
of urine in twenty-four hours. When six years of age, from sixteen 
to twenty-five ounces will be passed with a specific gravity under 
1. 01 5. From this age until puberty both the quantity and specific 

349 



350 



THE URINE 



gravity gradually increase, the usual range in specific gravity being 
from i.oio to 1.020. 

Method of Collecting Urine. — The collection of the amount voided 
in twenty-four hours in children of the "runabout" age is difficult, 
and in young infants well nigh impossible. For accurate work 
the specimen should be obtained by the catheter. When for any 
reason this is not possible, there are various devices for collecting the 
urine, any one of which may be tried. The tying on of a wide- 
mouthed bottle or a condom in boys, fastening it with adhesive strips 
to the body, is often successful. Absorbent cotton into which the 
child urinates, the urine being expressed from it into a bottle, may 
be used for either boys or girls, as may also the Chapin collector 
(Fig. 39). The chief disadvantage of any of 
ft these measures is the certainty of contamina- 

V,l tion. The urine so collected may answer for 

!• ;i an examination for albumin, sugar, or the renal 

elements, but is useless for a bacterial study. 
From the second to the third year conti- 
nence at night is usually established. If in- 
continence continues after the third year, the 
case should be looked upon as abnormal and 
receive treatment accordingly. (See Inconti- 
nence of Urine, page 352.) 

Urinary disorders 

Difficult and Painful Urination.^ — Painful 
urination is of frequent occurrence in in- 
fants and *' runabout" children. It may 
be due to irritation at the urethral outlet fol- 
lowing injury or to scalding from acid urine, 
but more frequently the irritation is due to 
lack of cleanliness of the parts, which remain 
moistened, and inflammation results. 

In two cases I have found calculi in the 
urethra. Both were in boys about five years 
of age. By far the greater number of patients who suffer from dif- 
ficult micturition are boys, and it is due to phimosis with adhesions 
and retained smegna. Attention to the external genitals in the 
matter of cleanliness, the operation of circumcision, or the relief of 
adhesions by sHtting the foreskin and freeing the glans, promptly 
reUeves the condition. 




Fig. 



39. — Chapin Urine 
Collector. 



RETENTION AND SUPPRESSION OF URINE 

In using the above terms with reference to diseases of the urinary 
organs it is well to appreciate their significance. By suppression is 
meant a condition of anuria in which no urine is passed into the blad- 
der, that viscus being found empty on catheterization. In retention^ 



RETENTION AND SUPPRESSION OF URINE 35 1 

the urine is secreted by the kidneys and passed into the bladder but is 
not voided. When the urine is not voided, we must always ascertain 
whether there is suppression or retention. If there is retention, it 
can usually be discovered by palpation and percussion. In fat chil- 
dren a positive diagnosis may be impossible by this means. In any 
event, when in doubt, a catheter should be employed. For infants 
under one year of age a soft-rubber catheter, No. 4 or 5 American, 
should be used. If suppression is diagnosed and treatment b}^ diu- 
retics instituted, when there is simple retention, no little trouble will 
result, as I have occasionally seen. 

Suppression of the urine may persist for hours without any grave 
pathologic condition of the kidneys. Chilling of the skin surface 
may be a cause. In acute gastro-intestinal disorders with frequent 
vomiting and watery stools there may be suppression for twenty- 
four hours. The secretion is re-established when there is again an 
available fluid to be added to the circulation from the digestive tract. 
If the suppression is due to causes of a grave nature, such as acute 
nephritis, there will usually be signs of trouble other than the sup- 
pression, such as vomiting, fever, and edema. 

Retention may result from an injury to the urethra, or in girls 
from vaginitis or in boys from phimosis. Impacted stone in the 
urethra was a cause in two boys seen by me. Fortunately in each 
case the stone was located near the meatus and readily removed. 
The bladder of the infant and young child is very readily infected and 
care should be exercised to have the catheter sterile before it is used. 

Local Treatment of Retention. — The immediate relief of reten- 
tion is by catheterization. Further treatment consists in the correc- 
tion of the exciting cause. If a catheter is not at hand, the application 
of a hot stupe over the lower portion of the abdomen and the genitals 
may be sufficient to stimulate urination. The use of a soap-sud 
enema, producing an evacuation of the bowels, is often sufficient to 
cause an emptying of the bladder at the same time. It is always 
advisable to attempt relief through the use of the hot stupe or the 
enema before resorting to catheterization. 

Local Treatment of Suppression. — Colon flushing is one of the 
most effective measures of relieving this very urgent condition. 
The apparatus required and the methods employed will be found on 
page 219. If the temperature of the patient is not above 102° F., 
the normal salt solution, at a temperature of 110° F.,is advised. I 
have always found the flushing more effective when this degree of heat 
was used. One pint is introduced, for a child three 3- ears of age. In 
children of one year or under, from four to eight ounces is all that will 
be retained. It must not be repeated, however, oftener than once 
in six or eight hours, as the colon of a child soon becomes intolerant 
of the injections and but little will be retained. Repeatedly, after 
the first injection, the kidneys have resumed activity when all other 
means have failed. It has been particularly useful in cases following 



352 THE URINE 

or accompanying the exanthemata, where there was an acute ne- 
phritis with greatly diminished secretion of the urine. 

INCONTINENCE OF THE URINE; BED-WETTING? ENURESIS 

The involuntary discharge of urine is normal in the young infant. 
Urination becomes a voluntary function at a later age, the time de- 
pending largely upon the child's training. In most children, with the 
right kind of management, it may be controlled during waking hours 
by the tenth month. During sleep, it continues to a later period, 
and while in many cases it may be under perfect control at the com- 
pletion of the second year, I do not regard the loss of control as 
abnormal until the third year is completed. If during the second 
year the child shows a tendency to frequent urination and involuntary 
passage of urine during waking hours, with habitual incontinence at 
night, it is my custom to advise preventive measures. 

In some of these children the urine is very acid and of a high spe- 
cific gravity — 1.020 or over. In such cases a reduction of the 
quantity of the highly nitrogenous food-stuffs in the diet, especially 
meat and eggs, is often followed by improvement — the eggs and red 
meat being given alternately not oftener than every second day. 
Where the urine is normal, the quantity of fluids given during the 
twenty-four hours is reduced from 25 to 50 percent and more solid 
nourishment substituted. 

When the incontinence persists during waking hours at the com- 
pletion of the second year, or during sleep at the completion of the 
third year, the condition is regarded as abnormal and the child placed 
under treatment. 

In assuming the care of a child with incontinence our first step is 
to discover the cause of the trouble. With this object in view the 
patient is examined with the idea of discovering any peripheral ab- 
normality which may have a bearing on the disorder. Thus the 
incontinence may be due to a vaginitis or to an adherent clitoris in 
girls, or to phimosis in boys; it may be due to thread-worms in the 
rectum, to constipation, to stone in the bladder, to cystitis — a very 
rare condition, and to hyperacidity of the urine — a very common 
one. The diet also may play a part. The use of highly nitrogenous 
food in large amounts, or a diet rich in sugar may lead to changes in 
the urine sufficient to cause the trouble. The presence of adenoid 
growths in the nasopharyngeal vault is supposed by some writers to 
cause enuresis. As a result of the diurnal and nocturnal inconti- 
nence, the bladder may never have developed and its capacity may 
be greatly reduced. Obviously, when such is the case, incontinence 
will be noted both day and night. 

After all possible dietetic and peripheral causes have been elimi- 
nated, about 90 percent of the cases remain. These are due to a 
neurosis, and are not dependent upon any discoverable pathologic 
condition. There is a lack of development, a weakness of the vesical 



INCONTINENCE OF URINE; BED- WETTING; ENURESIS 353 

Sphincter, and a lack of coordination of those portions of the sympa- 
thetic nervous system which control micturition. 

Treatment. — If due to peripheral causes they must be corrected 
and the general physical condition of the child improved, although 
in my experience the delicate and chronically ailing are not the chil- 
dren who are the greatest sufferers. By far the larger number of my 
patients have been well-nourished children who were otherwise nor- 
mal. Long-continued incontinence does not appear to affect the gen- 
eral health. When well established, the condition, untreated, usually 
continues until the child is eight or ten years of age. I have known 
of a few cases which persisted until puberty. 

If no improvement follows the removal of all possible dietetic 
and peripheral causes, we must assume that we have an idiopathic 
incontinence to deal with. If the case is of several months' or years' 
standing, with nightly incontinence, once, twice, or three times, we 
must acquaint the mother with the fact that prolonged treatment 
will in all probability be required, and that unless her active and 
continued cooperation is assured, the treatment of the case will not 
be undertaken. 

Illustrative Cases. — To show how untiring must be our efforts, 
a recital of an early experience with twelve inveterate bed-wetters 
may not be without interest. Several years ago, while resident phy- 
sician at the New York Infant Asylum, twelve patients, nine boys 
and three girls, ranging in age from six to ten years, were selected for 
treatment. All were in fair health. No local cause for the enuresis 
could be discovered in any of them. They had been given the 
usual treatment with strychnin, belladonna, and other drugs without 
improvement. They had always been bed-wetters. All wet the bed 
two or three times during the night, and three suffered from daily 
incontinence as well. The oldest, a boy of ten, with incontinence 
by day and night, pronounced incurable, had been returned to us 
from the West, where he had been sent by The Children's Aid Society. 

The patients were put to bed at seven o'clock and wakened at 
ten, to urinate. The medication suggested below was used. Symp- 
toms of atropin poisoning occurred in three in the form of a typical 
belladonna blush and excitement. After six weeks of treatment 
there was slight improvement in four. One or two nights a week 
would be passed without bed-wetting. At the end of the third 
month the lapses were but once or twice a week. Seven were prac- 
tically well at the end of the fifth month, rarely wetting the bed. The 
treatment was continued two months longer, when the dose was 
reduced one-half, again continued for two months, and then stopped, 
and nine months after final discontinuance there had been no return. 
The remaining five cases, all over six years of age and including all the 
girls, showed but slight improvement after the fifth month of treat- 
ment, the incontinence being of almost nightly occurrence. During 

23 



354 THE URINE 

the next three months the improvement was gradual, and at the end 
of the eighth month incontinence occurred not oftener than twice a 
week, and during the tenth month it was only occasional. The dose 
was reduced one-half, and after one year of continuous treatment 
there was no return of the trouble. The atropin was stopped, and 
six months later the cure was apparently complete. 

These cases need not cause discouragement, as they were invet- 
erates, all over six years old, and the oldest ten. They had always 
wet the bed and had resisted all previous treatment. 

Frequently a treatment of from four to six weeks or even for a 
shorter time effects a cure. The child receives three meals daily. 
The breakfast and dinner correspond to the age of the child, but one 
should emphasize the fact that red meat is to be given but once during 
the twenty-four hours. The supper, which should not be later than 
six o'clock, I designate a "dry supper." It may consist of any cereal, 
such as rice, hominy, farina, or wheatena, served with butter and sugar. 
If this is not well taken, a small quantity of both sugar and milk may be 
added. Permissible articles for the evening meals in addition to the 
above are: ice-cream, milk-toast, blanc-mange, raw fruit, jelly, 
stewed fruit, bread and butter. Meat, eggs, or heavy foods of any 
kind should not be given at night. At four o'clock in the afternoon 
the child is given as much water as he wishes, but no fluids after this 
time are allowed, other than a little milk on the cereal. The abstinence 
from all fluids after 4 p. m. will at first be a hardship for some children, 
and they may be allowed a small quantity — three or four ounces of 
milk or water — with the evening meal; but this quantity should 
gradually be diminished until at the end of a week it will not be 
missed. 

The child should be as lightly covered at night as comfort will 
permit. There is less tendency to incontinence if the child rests on 
his side or stomach. Sleep in this position should be encouraged. 
In inveterates, where every possible aid is brought into use, I have 
used the knotted towel as a means of keeping the child off his back. 
A knot is tied in the middle of the towel. It is then passed around 
the child so that the knot will rest on the back. If it is long enough, 
the ends of the towel may be pinned together over the abdomen like 
an abdominal binder. When the child attempts to rest on the back 
the knot causes discomfort and the position is changed. At 10 or 
II o'clock, when the person in charge retires, the child should be 
taken up to urinate. 

Drugs. — Without a strict observation of the above measures, 
particularly those referring to diet and the abstinence from water after 
4 p. M., drugs are of no value, whatever their method of administra- 
tion. With the above suggestions carried out, we have one remedy 
which is of great value, and that is belladonna. For convenience of 
administration I prefer the alkaloid, atropin. To get the full benefit 



drop 


7 p. M. 


1 drop 


1 " 




2 drops 


2 drops 




2 " 


2 " 




3 " 


3 " 




3 " 


3 " 




4 " 


4 " 




4 " 


5 " 




5 " 



INCONTINENCE OF URINE; BED- WETTING; ENURESIS 355 

of the treatment in severe cases it must be pushed till we obtain the 
physiologic effect, as shown by a slight dilatation of the pupils. Be- 
fore beginning the treatment it is well to advise mothers that a red- 
ness of the skin need cause no alarm, but that when it is noticed they 
should discontinue the drug until further instructions are given. 
The atropin is administered as follows: One grain is added to an 
ounce of water; one ounce of water contains approximately 500 
drops, so that one drop of the atropin solution would contain ap- 
proximately 5-Q-0 grain of the drug. The mother is given a chart 
containing the directions for administration, which for a child five 
years of age are as follows : 

1st day 4 p. M., 

2d " " 

3d " " 

4th " " 

5th " 

6th " 

7th " " 

8th " 

The child is given one drop daily at 4 and 7 p. m. for every year 
of its age. Thus, for a child three years old the dosage should not 
be greater than three drops, twice daily ; for a child six years old not 
over six drops, twice daily, would be given. It may be well, if the 
case is not under close observation, to make a more gradual increase 
in the dosage so as to avoid the possibility of unpleasant physio- 
logic effects. 

It is never advisable to exceed these doses even in older children, 
for the reason that they are sufficient to control the enuresis; and 
the dilated pupils and belladonna blush which follow the increased 
doses show that such doses are unnecessary. 

The tolerance of atropin varies considerably, although children 
usually bear it very well. Now and then a child is treated who 
cannot take more than two drops (^io" grain) daily. To one boy 
eight years of age but 2-^-0 grain could be given twice daily. Pro- 
nounced benefit, ordinarily, will not be observed during the first 
week or two of treatment. If the child suffers from incontinence 
while awake, this will first be cured. The improvement in nocturnal 
incontinence is more gradual and may be considerably delayed. 
Thus, no improvement whatever may be seen for two or three weeks. 
In the cases cited above it will be noticed that, in three, no improve- 
ment occurred until the sixth week. In the average case the im- 
provement is gradual. Instead of wetting the bed every night there 
will be nights at short intervals when there will be very slight 
incontinence, or none at all. 

Usually after a few weeks' treatment the incontinence entirely 
ceases. The mistake frequently made is to stop the atropin at this 



356 THE URINE 

point. When this is done there is usually an immediate return of 
the trouble. The full treatment should be continued until the child 
has ceased wetting the bed for at least two weeks, when the daily 
amount of atropin should be reduced one-half and kept at this point 
for six weeks. If at the end of two months from beginning treat- 
ment there is no incontinence, the drug may be discontinued, but 
the dietetic regulations, particularly the "dry supper," should be 
continued for three months longer. It must be remembered that 
the element of habit, which has become established, is hard to 
overcome, even after the neurosis and the sphincter weakness have 
been corrected. 

Strychnin and tincture of cantharides have been advocated by 
pediatric writers. In weak, poorly nourished children strychnin 
may be added to the iron or oil tonics, and, as a tonic, be of 
service in improving the general condition of the patient, and 
indirectly be an aid in the treatment of the enuresis. When in- 
continence occurs only during the day, the dietetic regulations are 
the same, with the exception that the fluids allowed need not be cur- 
tailed unless the quantity is excessive. The dosage of atropin is the 
same, but the time of administration should be changed to after 
breakfast and after luncheon, instead of at 4 and 7 p. m. In addition 
to the atropin, strychnin should always be given in cases of inconti- 
nence by day, as a lack of development or a relaxation of the sphincter 
is more of a factor with them than is failure of nerve coordination. 

A fact to be taken into consideration in making a prognosis as to 
the probable duration of the treatment in a given case is the size of 
the bladder, since a child who has suffered from incontinence both 
by day and night may have a small and contracted bladder because of 
lack of development from disuse. In one of my cases, in a girl five 
years of age, the bladder had a capacity of but one ounce. The 
most reliable means of determining the size of a bladder is by meas- 
uring the amount of sterile water which can be introduced through a 
catheter. 

ALBUMINURIA 

Albuminuria may be either transient, cyclic, febrile, or paroxysmal, 
these terms indicating the different conditions under which albu- 
min is found in the urine. Aside from the albumin, there may 
be no indication of organic kidney disease, either clinically or micro- 
scopically. In children the presence of albumin without other signs 
of trouble is of much greater import than is a similar condition in 
adults. The absence of proof of a kidney lesion does not mean that 
such a process may not exist. My own experience with cases of so- 
called functional albuminuria has not been a particularly pleasant 
one. 

More or less persistent albuminuria, regardless of its association 
with muscular exertion or mental excitement, means that a tempo- 



ACUTE NEPHRITIS 357 

rary change is taking place in the renal epithelium. Frequent repe- 
tition of such processes readily leads to organic changes, and I am 
always disturbed b}^ the presence of albumin, as I consider the con- 
dition one not to be lightly regarded. One of my cases, now under 
treatment, shows a trace of albumin after eating an egg, and in three 
of my cases, a diet rich in meat and eggs will invariably be followed 
by albuminuria. 

Treatment. — The management of these cases involves the dis- 
covery and removal of the source of the irritation. If caused by 
emotion, exertion, or diet, a correction of the child's daily habits 
should be made along rational lines. I require these patients to be 
given a diet free from eggs, while red meat is allowed not oftener 
than twice a week. They are to avoid sudden exposure to cold, to 
wear flannel next to the skin nine months in the year, and light- 
weight silk-and-wool undergarments during the hot months. They 
are not allowed to indulge in hard play. Baths below 80° F. are 
not to be given them. Ocean bathing is prohibited. A salt bath 
(page 31), followed by a brisk friction with a coarse towel, is given 
at bedtime. The activity of the skin is thus insured. The bowels 
are kept open by the free use of fruits and the malted foods. If a 
laxative is required, salines are preferred. The case should be 
under observation, the above precautions observed, and the urine 
examined at intervals of tw^o or three months for one year after the 
last negative examination for albumin. 

ACUTE NEPHRITIS 

Nephritis, in common with many other ailments of children, may 
be either mild or severe. It may be so severe as to cause death in a 
few hours or so mild as to pass unrecognized. The disease is rarely 
primary, being usually due to some systemic infection. The treat- 
ment of the severer forms of nephritis is often open to the most em- 
phatic criticism, reflecting as it does the present methods of the 
schools, in their advocacy of forced, indiscriminate water-drinking, 
the exclusive milk diet, and the more or less indiscriminate use of 
diuretic drugs. Every one of these measures is capable of, and has 
been productive of, no little harm. Too great emphasis has been 
placed upon forcing the kidneys to act and too little upon the neces- 
sity of relieving them of the work for which they are temporarily 
incapacitated. The advocacy of drinking large amounts of water 
when the kidneys, distended with blood and the tubules obstructed, 
are secreting but very little, does nothing but harm. Under similar 
conditions, heart stimulants, such as digitalis, which forces more 
blood into the kidneys, necessarily make a bad condition worse. 

Treatment of Mild Cases. — In treating nephritis, there are several 
factors to be kept in mind. Because a case is mild it should never 
be given scant attention. Nephritis in a child may be most insidi- 



358 THE URINE) 

ous in its course. The mildest case, while not treated in all respects 
like a more severe one, should be given every possible attention as to 
rest in bed and diet, for through neglect, even for a very few hours, 
it may become most severe. 

A child with nephritis must be kept in bed with the temperature 
of the room at about 70° F. He should be protected from drafts of 
cold air. Silk, a mixture of silk and wool, or flannel should be worn 
next to the skin. 

Diet. — The nutrition of the patient is to be maintained by food 
which will not add to the existing trouble. We are told in the books 
that nitrogenous food, such as meat and eggs, is to be avoided in order 
to relieve the kidneys from the work of the secretion of urea and cre- 
atinin, and yet often we are advised in the very next line to give a full 
milk diet, which in a child from five to ten years of age means from 
two and one-half to three quarts daily, which, it will be remembered, 
contains 4 percent of nitrogenous food proteid. A diet necessitating 
that large amount of nitrogenous waste (by-products) will have to be 
excreted by the kidneys. In order to maintain the nutrition of the 
patient, proteid is necessary, and may be supplied by the use of a 
moderate amount of milk. For a child under five years of age, from 
sixteen to twenty ounces of full milk should be given daily — never 
more than twenty ounces. This is diluted with equal parts of 
cereal gruel, No. i or 2, with the addition of one teaspoonful of 
sugar (see formulary, page 1 30) , and given in quantities of from six 
to ten ounces at four-hour intervals. This supplies all the nourish- 
ment necessary for a patient of this age. In order that the diet may 
not become monotonous to the child and cause loss of appetite, as 
is almost always the case when full milk is used, the taste of the food 
may be changed by the use of cereal gruels of different kinds. 
Broths and beef extracts are not given because of their creatinin 
content. Zwieback and butter, stale bread and butter, prune- juice, 
thin apple sauce, and orange-juice may be given in order to improve 
the digestion and add variety to the diet. Inasmuch as milk cannot 
be taken at the same time as fruit by many patients, it may be given 
between meals or with a plain meal gruel. 

Bowel Evacuation. — A patient with nephritis, no matter how mild, 
should have two movements daily. These should be rather loose. 
The use of the fruit- juices may be sufficient to keep the bowels relaxed. 
If a laxative is necessary, citrate of magnesia or, in very young children 
and infants, milk of magnesia may be given in such doses and at such 
intervals — either of twelve or twenty-four hours — as may be neces- 
sary to produce the desired results. Twenty-four hours should not 
pass without an evacuation of the bowels. The patient should 
always have an enema at bedtime, if no passage has taken place dur- 
ing the preceding twenty-four hours. 



ACUTE NEPHRITIS 359 

There should be a warm sponge-bath daily, the body being 
sponged and dried in sections under a flannel blanket. 

Prophylaxis. — If during scarlet fever or any of the infectious dis- 
eases the physician takes the precaution of having nitric acid and a 
few test-tubes at the home of the patient, so that the urine may be 
tested for albumin at each visit, with a reasonably frequent micro- 
scopic examination at his office, a nephritis may be detected before 
the more active clinical signs of the disease appear, and thus by plac- 
ing the patient promptly under the above management, usually but 
little trouble will be experienced. In fact, in a majority of the 
cases the above suggestions are all that are necessary to carry the 
patient safely through an attack, if the kidney involvement is detected 
early and if diuretic drugs are omitted from the treatment. The use 
of additional measures for the more severe cases will depend, to a 
considerable extent, upon the individual case. 

Treatment of Severe Cases. — ^When there is fever with partial 
suppression of the urine, only one-half the usual quantity being 
passed and that loaded with albumin, blood, and casts, with per- 
haps beginning edema, colon flushings (page 518) with a normal salt 
solution at a temperature of 110° F. are to be used. The flushings 
have the effect of increasing the functional activity of the kidneys. 
For a child from five to ten years of age, one pint of the warm saline 
solution may be thrown into the colon. An effort should be made to 
have the child retain it by having him rest on his left side with the 
buttocks elevated on a pillow. In young children from eight to 
twelve ounces ma}" be used, and in infants under nine months, from 
four to six ounces is all that we may hope to have retained. The 
flushings should not be repeated oftener than at twelve-hour inter- 
vals, unless the condition is urgent, as an intolerance of the parts is 
readily brought about by too frequent manipulations. 

If there is a hot, dry skin with a tendency for the temperature to 
remain above 102° F., tincture of aconite is given in small doses. 
For a child three years of age, one -half drop is given at two-hour 
intervals. Older children may be given one drop at a dose. It is 
rarely wise to increase it above two drops at two-hour intervals even 
in children above ten years of age. Only sufficient should be given 
to produce a slight diaphoresis, for by keeping the skin constantly 
moist the blood-vessels of the kidneys are relieved of the tension to 
which they have been subjected. 

In the severer forms with edema or anasarca, cases in which but 
two or three ounces of urine are passed daily, more active measures 
will be required. In these urgent cases the diet should consist tem- 
porarily of thin gruels of barley, granum, or rice (No. i), with sugar 
added to make them more palatable, and diluted fruit- juices given 
between the feedings. In a carbohydrate diet there are no by- 
products irritating to the kidney. Water should be given scantily, 



360 the: urine 

sufficient fluids being given in the food. Active measures to increase 
the diaphoresis and thus reUeve the kidneys must be instituted. 
The best means of doing this is by the use of hot colon flushings, hot 
packs, and hot baths. In these cases it is by attempts at forcing 
the kidneys, by the use of digitaHs and the alkahne diuretics, that we 
do an immense amount of harm. DigitaHs drives more blood into 
the kidneys and thus increases the congestion. The alkaline diuretics 
disturb the stomach, which is already showing signs of food intoler- 
ance. Colon flushings at 110° F. are now to be used every six hours. 
This is probably one of the most valuable means we possess for re- 
lieving the congestion of the kidney and inducing a flow of the urine. 

Heat, either dry or moist, is to be brought immediately into use 
in order to stimulate the skin to vigorous action. Both dry heat and 
moist heat have their advocates. Placing a child in a warm bath at 
105° F., keeping him there for a few minutes, 
drying rapidly, and immediately putting him 
into bed, surrounded by hot-water bottles, will 
usually produce diaphoresis. A thermometer 
should be placed under the bed-clothing so 
that excessive heat may readily be detected. 
I have seen pronounced weakness produced 
by excessive heat used for such a purpose. 
The child should not be allowed to rest in a 
temperature higher than 120° F., and this 
should not continue for over ten minutes. A 
temperature of 105° F. or 110° F. may be 
maintained for an hour if necessary. If the 
packs are used, they may be repeated once 
^'%vs''~S''^TnK K^iLtfER ^^ six hours. The disadvantages of a hot 
Croup Kettle. bath are duc to the fact that it necessitates 

considerable handling, which to some pa- 
tients is a cause of no little excitement. In such cases, dry heat 
may be substituted. The patient is warmly clad in flannels and 
hot-water bottles are placed near him. This may be sufficient to 
induce perspiration. A device which I use consists of a funnel 
attached to a one-inch brass pipe which is bent in the middle to a 
right angle and which conducts the warm air under the bed-clothing. 
The heat is generated by a kerosene lamp, over the top of which an 
inverted funnel is placed at a sufficient distance to allow combustion 
to take place. The Kilmer croup kettle has an appHance which 
may be used for this purpose (Fig. 40). 

While a free secretion of urine is desired in these cases, we must 
not be content with that alone. Uremia may occur even while the 
normal amount of urine is being passed. A quantitative test for 
urea should be made in all severe cases in order to determine the 
amount excreted. Normal human urine contains, roughly speaking, 




ACUTE NEPHRITIS 361 

2 percent of urea, which occasionally in health rises to 3 per cent. 
Approximately 0.5 gram of urea is excreted per kilogram of body- 
weight. The proportion in children is relatively higher/ 

Treatment of Uremic Convulsions. — Vomiting is one of the first 
symptoms of uremia. When it occurs, all food should be temporarily 
withheld from the stomach and nutrient enemata given by rectum. 
Completely peptonized skimmed milk is our best means of nutrition, 
from four to twelve ounces being given every four to six hours. It 
is best to give large quantities at long interv^als — every six hours is 
best, as the manipulations with the tube have a tendency to produce 
intolerance on the part of the gut. The tube should be introduced 
at least eight inches into the bowel and the solution used should be 
lukewarm. A temperature of 95° or 100° F. will best be retained. 
In addition to the use of colon flushings and external heat, uremic 
convulsions should be controlled w^ith chloroform or the rectal ad- 
ministration of the bromids or chloral. For a child under three years 
of age, from two to three grains of chloral may be given with eight 
grains of bromid of soda. After the third year, three grains of 
chloral may be used with from eight to fifteen grains of bromid 
of soda. It is best retained when given in at least four ounces of 
mucilage of acacia or skimmed milk, the enema being repeated in 
four or six hours. 

When heart stimulants are required, tincture of strophanthus is 
usually given — from one to two drops at two-hour intervals to a 
child under three years of age. After this age, from two to three 
drops may be given. Digitahs is sometimes used as a heart stimulant 
during convalescence, after the secretion of the urine has been estab- 
lished. 

Convalescence. — Convalescence is often tedious in these cases. 
The child should not be allowed to be out of bed until albumin has 
disappeared from the urine. For at least six months after an attack, 
the urine should be examined weekly. Light-weight woolens should 
be worn next to the skin during the entire year and every effort made 

^R. Bradford, in AUbutt's "System of Medicine" : 

Amount of Urea Excreted on the Basis of 0.5 Gram per Kilograivl 

1 vear ^ ^^^^ ^^^ 4.645 

1 year ^q^i^ §24* • 412 



3 years 



/Boys 14,14 7.07 

\ Girls 13.60* 6.80 

/ years -^ ^.^^^ 21.78* 10.89 

lu years ^ ^..^^^ 29.07* 14.535 

13 vears ^ ^"^^ ^^'^^ 20.02 

1^ years ^ ^^^^^ 41.36* 20.68 

16 vears ^ ^""^^ ^^"^^ 28.045 

10 years ^ ^^^^^ ^^ 24* 25.62 

* Figures of Boas, quoted from Holt. 



gms. 


in 


24 hrs 


gms. 


m 


24 hrs 


gms. 


m 


24 hrs 


gms. 


m 


24 hrs. 


gms. 


m 


24 hrs 


gms. 


m 


24 hrs 


gms. 


m 


24 hrs 


gms. 


m 


24 hrs 


gms. 


m 


24 hrs. 


gms. 


m 


24 hrs 


gms. 


m 


24 hrs 


gms. 


m 


24 hrs 



362 THE URINE 

to protect the patient from sudden exposure to the influence of cold 
air. With the advent of future illness with fever, even though it does 
not occur for a year or two afterward, unusual precautions should be 
taken to protect the child, in view of a possible reinvolvenient of the 
kidneys with, possibly, a resulting chronic nephritis. Meat and eggs 
should be given scantily for a year after an attack. Exercise calling 
for great muscular effort should not be allowed for a considerable time, 
at least for a year after all trace of the nephritis has disappeared. I 
advise that, when possible, the winter after an acute attack be spent 
in a warm climate, such as that of Florida or Lower California. 

Scarlatinal Nephritis. — A form of acute nephritis which deserves 
particular attention occurs early in malignant scarlet fever. The 
onset is very abrupt. But little urine is passed, and this is filled 
with albumin and casts and blood. In a recent case complete sup- 
pression occurred without previous warning and the child died in 
thirty-six hours, the duration of the. entire illness being but seventy- 
two hours. There was no edema. The child became comatose and 
died from the uremia and the intense scarlatinal poisoning. In these 
cases repeated hot baths and packs, 105° to 110° F., should be used 
in spite of the high temperature which is usually present. Frequent 
hot colon flushings, 110° F., should also be given. Heart stimulants 
hypodermatically may be of value. The prognosis in these cases 
is very unfavorable. 

CHRONIC DIFFUSE NEPHRITIS 

This disease is rarely seen in children under three years of age, 
and it is almost invariably the result of an acute process which ran its 
course unrecognized, or of faulty management following an acute 
nephritis. The following history is quite a common one : A patient 
who came under my care three years ago with chronic nephritis gave 
a history of having had three distinct acute attacks during the pre- 
vious four years, with intervals of apparent health. The urine had 
not been examined during these intervals nor had she had the ad- 
vantages of proper treatment. 

Treatment of the Milder Cases. — The management of chronic 
diffuse nephritis in children resolves itseff into care in four respects: 
diet, climate, baths, and exercise. 

If the patient is confined to the bed, the diet should be the same 
as suggested under acute nephritis. One quart of milk may be given 
daily. If the child is up and about, meat may be given once every 
second day. Eggs should be excluded. In other respects the diet 
should be simple, as outlined for well children (page 134), this being 
ample for nutrition. 

The child should receive one warm bath — 95° to 100° F. — daily, 
followed by a brisk friction with a dry towel. 

An outdoor life is of decided advantage; exertion, however, 



CHRONIC DIFFUSE NEPHRITIS 363 

should not be allowed to the point of fatigue. Contests or stress of 
any kind, mental or physical, should not be permitted. 

If possible, the child should spend the colder months in a climate 
which is not subject to sudden or wide variations in temperature. , 
The cUmate furnished by Florida or Lower California is advocated 
when the parents are financially able to give the patient the benefit 
of it. If, howcA^er, he must be kept in his home, which does not offer 
the advantages of an equable climate, great care should be exercised 
in preventing sudden chilling of the skin surface. Woolens should 
be worn next to the skin at all seasons of the year. Frequent exami- 
nations of the urine should be made, not only for albumin and casts, 
but for urea as well. Sudden attacks of uremia may occur even 
while the patient is passing an excessive amount of urine. 

Treatment of the Severer Cases. — The patients are always the 
occasion of a great deal of solicitude. My results have not been 
brilliant. In some of my cases the illness began after an infectious 
disease, usually scarlet fever, and ran a slowly progressive course, 
which under the best of management defied every effort, the illness 
terminating fatally in three months to a year. 

In other cases improvement occurred. Casts and albumin dis- 
appeared from the urine and the child was apparently well. An 
exposure, some intercurrent disease, or from some unknown cause 
an exacerbation occurs, and the attack is repeated, usually of a graver 
nature than the previous one. The urine becomes scanty and loaded 
with albumin and casts, the child becomes edematous and pale. 
Treatment will perhaps relieve the condition, to be followed by 
another attack in three to six months, with an interval of apparent 
health. In one girl four years old, five distinct recurrences took 
place before death, which completed the fifth attack. A girl nine 
years old gave a history of a chronic nephritis lasting two years. 
For six months, since under my care , the kidney condition remains 
apparently normal. A boy aged four remained well for two years 
after an illness covering six months. After the period he passed 
from under my observation. 

The management of the suppression and anasarca is very much 
the same as for the condition occurring in acute nephritis (page 359). 

Diuretics with which the physician is familiar and has faith may 
be given well diluted, so as not to disturb the stomach. 

In the mild cases the diuretic potash salts, spirits of ether, nitrosa, 
and infusion digitahs appear to be of benefit. 

In the severe forms of chronic diffuse nephritis I haye yet to see 
a diuretic of the slightest value, as I have within the last three months 
seen two cases in which every possible diuretic and combination of 
diuretics were used without avail. Both of these patients were girls ; 
one terminated fatally after six weeks' illness. The second girl, three 
years old, was a patient in the Babies' Hospital, in my ser^dce. She 



3^4 



THE URINE 



presented the typical picture of advanced chronic nephritis (see Fig. 
41). The usual treatment with calomel, salines, colonic flushings, 
and hot packs and diuretics failed to make any impression. The 
urine presented the usual changes and was very scanty. After two 
weeks of treatment without making any impression on the case, the 
child becoming constantly worse, the Bdebohl's operation of decapsu- 
lation of the kidney was performed by Dr. William A. Downes, of 
New York City. The kidney secretion gradually increased, the 
urine showing but a trace of albumin two weeks after the operation. 



ri 









Fig. 41. — Chronic Nephritis Befori 
Edebohl Operation. 



Fig. 42. — Same Case as Fig. 41 After 
Edebohl Operation. 



The thirteenth day following the operation the child had lost i6^ 
pounds in weight and presented the appearance seen in Fig. 42. There 
was an interval of two weeks between the time of taking the two 
photographs. 

During the convalescence from the operation the child developed 
a very severe colitis, in which she died six weeks after the operation. 
I look upon this case as a remarkable demonstration of temporary 
value (at least) of decapsulation of the kidney. Unfortunately the 
intercurrent colitis terminated the life before the permanent effects 
could be determined. 



GLYCOSURIA 365 

Chronic interstitial nephritis is very rare in children. I have seen 
one case in a patient ten years of age who had been ill two years. He 
was passing a large daily amount of urine — 60 to 90 ounces — an ex- 
amination of which showed a specific gravity of 1.002. There was 
but a trace of albumin. The boy died in a few weeks of acute uremia. 

GLYCOSURIA 

Temporary glycosuria or dietetic glycosuria is of frequent 
occurrence and is of little significance. It usually means that 
more sugar is being taken than can be cared for by the economy, 
and with a discontinuance of its excessive use the sugar disap- 
pears from the urine. 

Illustrative Cases. — In a series of observations made several 
years ago at the Country Branch of the New York Infant Asylum, 
ten children were selected for high-sugar feeding, 10 percent sugar 
mixtures being given to those under one year of age. Every 
case showed glycosuria after twenty-four hours of the high-sugar 
administration. 

Two most interesting cases of persistent glycosuria without 
any other manifestation of illness have been under my observa- 
tion for the past six years. That sugar existed in the urine was 
discovered by accident. How long it may have been present, we 
have no means of knowing. The mother, an unusually careful 
woman, conceived the idea that it would be wise to have the 
urine of all her four children examined. It was accordingly sent 
to me, and greatly to my surprise I found that two specimens, 
one from a boy of four years, the other from his brother of six, con- 
tained a large amount of sugar — 3 and 3.5 percent respectively. A 
careful examination was at once made of both patients, and nothing 
abnormal discovered. The children were strong, there was no 
unusual thirst and no polyuria, and, further, the examination 
of the urine failed to reveal the presence of either acetone or 
diacetic acid. They were placed on a rigid anti-diabetic diet (page 
367), which reduced the sugar to 1.5 and 2 percent respectively. 
During the seven years that have since intervened, the boys have 
made satisfactory physical and mental progress ; they have attended 
school regularly except when prevented by the usual ailments of child- 
hood. Both have undergone operation for adenoids and enlarged ton- 
sils under ether anesthesia, with no more than the usual discomfort. 
They have made normal increase in stature, weight, and strength, 
and are perfectlv normal in appearance. During these years monthly 
examinations have been made of the urine. There has never been 
less than i . 5 percent of sugar in either, and during the past eighteen 
months it has rarely been below 3 percent or above 6 percent, and 
that in spite of the most careful diet. There never has been polyuria 
or extreme thirst. The children have been seen bv several consult- 



366 THE URINE 

ants in New York City and have been under the treatment of 
three well-known specialists in Germany. Recently acetone has 
been found in the urine of one of the children. Probably every va- 
riety of treatment which might be expected to exert an influence on 
the sugar production has been tried for protracted periods without 
a particle of influence in reducing it. Indiscretions in diet increase 
the sugar, otherwise it ranges as stated above. None of the physi- 
cians here or abroad who have treated the boys has seen similar cases. 
They are cited in detail and are of much interest as showing the in- 
efliciency of medication in glycosuria and the effects of diet, and, 
furthermore, they present a clinical picture which is most unusual. 
It has been suggested that the glycosuria may be due to some 
persistent and unusual toxemia from intestinal sources, and the 
cases are now being studied on that theory. 

DIABETES INSIPIDUS— POLYURIA 

Persistent polyuria — diabetes insipidus — is rare in children. I 
have personally known of but one case. It had been but little influ- 
enced by six weeks' treatment at the time it passed from under obser- 
vation. Temporary or transient polyuria is of occasional occurrence 
and appears to be entirely of nervous origin. It is usually seen in 
nervous girls of hysterical tendencies. It is most apt to develop at 
the close of the school year, when a child is considerably reduced or 
somewhat excited in anticipation of undergoing examinations. The 
patient is thirsty, drinks quantities of fluid, and passes a great deal 
of pale urine of low specific gravity. Full doses of bromid of soda — 
ten grains three times daily — may temporarily relieve these condi- 
tions. In all the cases which I have seen, the polyuria ceased in a 
short time, with the cessation of school duties and a change of en- 
vironment. 

DIABETES MELLITUS 

But little of promise is to be offered in the management of diabetes 
mellitus in children. It is a particularly fatal disease. I have treated 
five cases, and all have terminated fatally. This is similar to the 
experience of all observers. The youngest patient was three, the 
oldest nine years of age. The manifestations of the disease were the 
same in all. There were excessive thirst, rapid loss in weight, the 
passage of large quantities of urine containing varying amounts of 
sugar, and a dry, roughened skin. Not one of my patients lived a 
year after the commencement of the disease. Death usually takes 
place in less than six months. 

The patients were treated by limiting the amount of fluid taken, 
by restricting the diet, and by using the opium derivatives and 
arsenic to the point of physiologic effect — all without the slightest 
benefit. The sugar output was reduced, but the patients showed 
not even temporary improvement as to their general condition. 



VESICAL CALCULUS. CYSTITIS 367 

Children with diabetes mellitus usually die from exhaustion or from 
some intercurrent disease like pneumonia. Uremia is of less frequent 
occurrence in children than in adults. 

Diet. — The following are permissible articles of diet for a child ill 
with diabetes : Soup and broths made from meat, fresh and salt fish, 
shell-fish occasionally, egg, fowl, and game, smoked meats, sweet- 
bread, cheese, spinach, celery, lettuce, cucumbers, cranberries, 
radishes, string beans, asparagus, squash, cabbage, egg-plant, to- 
matoes, onions, turnips, mushrooms, gelatin jellies sweetened with 
saccharin, butter, cream, olive oil, cod-liver oil, lemon, grape-fruit, 
sour apples, blackberries, raspberries, watermelon. Nuts of all kinds 
may be eaten. Only bread and biscuits made from gluten flour should 
be used. It is impossible to procure a starch-free gluten flour ; the 
flour, however, should not contain more than 20 percent of starch. 

VESICAL CALCULUS— STONE IN THE BLADDER 
Stone in the bladder is rarely seen in children under ten years of 
age. Two cases only have come under my obser^^ation. The pa- 
tients were boys aged respectively five and seven years. The treat- 
ment of the condition is entirely surgical. 

CYSTITIS 

Cystitis is an uncommon affection in children and I have never 
seen a case in a boy. In girls, however, it is of occasional occurrence, 
and is usualh^ due to an infection of the bladder with the colon bacillus. 

There is little or no pain attending urination, but there are 
frequent calls to urination, of the most urgent character. All of my 
cases of cystitis have suffered from incontinence of urine, during both 
waking and sleeping hours. We are sometimes told by the mother 
that the child asked to be taken to the toilet, but passed the urine 
before reaching it. Inability voluntarily to control the urine during 
the day, extending over a considerable period of time, points strongly 
to bladder involvement, either to store, which is exceedingly rare in 
children, or to cystitis. An examination of the urine usually clears 
up the diagnosis so far as the cystitis is concerned. 

Treatment. — The treatment is largely through internal medication, 
and is not particularly promising as regards the promptness of a cure. 
Irrigation of the bladder may be attempted. It has been of very Httle 
service in my hands. Bladder-washing is carried on with no little 
difficult}^ and annoyance and usually with unsatisfactory results. 
My best success has been by the use of urotropin — three grains, three 
times daily to a child three years of age. In cases due to the colon 
bacillus it is well to alternate the urotropin with citrate of potash, 
three grains of which are given three times daily, the urotropin being 
given alone for five days, followed by the citrate of potash for the same 
time, alternating thus, when necessary, until a cure is effected. 



368 ran urink 

ACUTE PYELITIS 

Pyelitis is a rare disease in children. All of my cases, nine in 
number, have been in girls under two years of age. In a great 
majority of the cases the disease is due to an infection of the pelvis 
of the kidney by the colon bacillus. In two there was a coHcystitis. 
The only symptoms in two of the cases were repeated severe chills, 
a very unusual occurrence in an illness in an infant, and a high tem- 
perature with a tendency toward wide fluctuations. The severe 
chills, the temperature ranges, and the absence of other clinical signs, 
together with a negative blood examination, suggested pyelitis. 
Examination of the urine revealed the colon bacillus. In the seven 
other cases there was an irregular temperature ranging from ioo° to 
105° F., which had continued from several days to three months. 

Four had been treated for different diseases, both typhoid and 
malaria having been considered. In two the temperature range 
was quite remarkable. As a rule, there is more or less temperature 
every day. In these two cases before and while under treatment 
there would be periods free from fever for five to ten days. Then 
there would be a rise lasting from twenty-four to forty-eight hours, 
sometimes not over twelve hours. In one of these, a girl of ten 
months, treatment was required for three months before the urine 
remained permanently free of pus. She had been ill six weeks. In 
the second case, a girl of thirteen months had been ill three months, 
probably longer. She was under my immediate care for six weeks 
without great improvement. She was then taken to a summer resort 
and, at the time of writing, ten weeks after instituting treatment, 
there is an occasional rise of temperature. 

Medication. — The treatment of pyelitis which has been success- 
ful in all of my cases consists in the use of urotropin. For a child 
one year old, from ih to 2 grains may be given at two-hour inter- 
vals, not over six doses in twenty-four hours. The urotropin acts 
best in an acid medium, the benefit resulting depending probably 
upon its being excreted unchanged in the urine, where it undergoes 
decomposition with the formation of formaldehyde; this does not 
take place when the urine is alkaline. If the illness promises to be 
persistent, as in the two last but one, I give the urotropin inter- 
ruptedly — i. e. , giving it for five days and rest three days. If the 
urine is very highly acid the citrate of potash may be given during 
the period of rest from the urotropin. The intervals of rest from 
the administration of urotropin is indicated because of the possible 
irritant effects produced on the kidney by the drug during prolonged 
usage. It has not been necessary in my cases to resort to the use of 
the coli vaccine for this form of urinary infection. 

Time Required for Cure. — There should be a period of six weeks 
free from pus before the case is pronounced well. The urine may be 
free from pus to-day, but present to-morrow. 



THE MALE GENITALS 

Practically every male child is born with an adherent prepuce 
and with more or less constriction at the preputial outlet. The 
penis is to be considered normal only when the foreskin can easily 
be retracted, laying bare the glans. 

The adhesions and constrictions may be relieved by moderately 
stretching the foreskin and breaking up the adhesions with a fine 
blunt probe, after which the glans should be cleansed, oiled, and the 
foreskin drawn forward over it. The cleansing of the parts with 
castile soap and warm water, which necessitates a retraction of the 
foreskin, should be practised at least every second day. This not only 
keeps the parts clean, but prevents the later formation of adhesions 
and a possible phimosis. 

Hypospadias and epispadias are conditions essentially surgical, 
and therefore are not considered here. 

PHIMOSIS 

Phimosis is a condition caused by a constriction or narrowing of 
the preputial orifice, sometimes to a pin-point. In cases where the 
foreskin is tightly bound to the glans by adhesions, the urine may be 
emitted in drops; in other cases the prepuce "balloons out" during 
urination and the urine dribbles away. The opening may be 
sufficiently large to show under pressure the margin of the urethral 
opening, and urination will be but little interfered with. 

Treatment. — The cases in which urination is impeded require 
prompt relief. This can be furnished temporarily by introducing a 
small probe or a director and carefully slitting the skin with sharp- 
pointed scissors until the glans is reached. The child should be 
carefully held by an attendant during the operation and great care ex- 
ercised in introducing the director. After the operation a wet dress- 
ing of bichlorid of mercury, i : 6000, or a saturated solution of boric 
acid should be applied to the wound until healed. 

A few years ago I saw a case in which the probe had been intro- 
duced into the urethra and followed up by the scissors, which had 
made a slit involving one-third of the glans. 

Phimosis may be productive of various nervous manifestations, 
such as restlessness and irritability. In two of my cases convulsions 
were apparently caused by phimosis. Both children had repeated 
convulsions until they were circumcised. Both suffered from marked 
phimosis with retained smegna and irritation of the prepuce. 
24 369 



370 THE MALE GENITALS 

Circumcision should never be delayed in cases of phimosis, as it 
furnishes the only satisfactory means of relief. Stretching is very 
apt to be followed by re-contraction, which only intensifies the origi- 
nal condition, while the unavoidable laceration of the mucous mem- 
brane may open a favorable field for infection. In hospitals and out- 
patient work, examples are numerous of the harm resulting from 
force and lack of cleanliness in the management of these simple and 
easily remedied conditions. 

PARAPHIMOSIS 

Paraphimosis is produced by the retraction of a tight foreskin, 
which later becomes so contracted behind the corona as to prevent 
the return venous flow. As a result, the glans become greatly swol- 
len, deeply congested, and edematous. Urination is impossible. 
The cases which I have seen have all been produced by the mother 
or nurse in an attempt to retract a tight foreskin according to 
the doctor's directions, after he had stretched the prepuce for 
phimosis. 

Treatment. — If the retracted skin is edematous, it may be punc- 
tured in various places to let out the fluid. Reduction may then be 
attempted by taking the glans between the thumb and the first and 
second fingers of the right hand and making gradual pressure back- 
ward against the thumb and first finger of the left hand, which grasps 
the penis behind the prepuce. If the reduction cannot be effected in 
this way, as occasionally happens, if the case is of long standing or the 
contraction very tight, a longitudinal dorsal incision may be made in 
the skin at the site of the constriction. After the reduction a wet 
dressing of a saturated solution of boric acid or of bichlorid of mer- 
cury, 1 : 10,000, should be kept constantly applied to the parts until 
the swelling has subsided, when circumcision should be done. 

BALANITIS 

Balanitis is a swelling and inflammation of the foreskin due to a 
local infection. Unskilled manipulation in stretching the prepuce 
readily produces a laceration, opening up a means of entrance for bac- 
teria. In severe cases the parts first show congestion and then edema. 
I have seen patients with long foreskins which were twisted and 
swollen to a size three or four times that of the penis. In advanced 
cases there will be suppuration beneath the foreskin with a purulent 
discharge from the orifice. 

Treatment. — If the case is seen early, a wet dressing made by 
wrapping the parts in gauze or old linen, which is saturated with an 
ice-cold solution of bichlorid of mercury i : 10,000 and changed every 
half hour, will usually be effective. If there is much edema, punc- 
turing in several places, after disinfection, should precede the wet 
dressing. If there is a purulent discharge, the sac should be gently 



CIRCUMCISION 371 

syringed at least twice daily with a 3 percent solution of hydrogen 
peroxid, diluted one -half with water. 

When the suppuration has ceased, with a return to normal of 
the parts involved, circumcision should be done. Operation during 
the acute stage, particularly with suppuration present, should be 
avoided unless the condition is very urgent. 

CIRCUMCISION 

Many times during the year I am asked the question, ''Shall we 
have the baby circumcised?" My answer as to the advisability of 
this operation, as a routine measure, is in the affirmative. The oper- 
ation during the second week of life is a trivial matter. I am con- 
vinced that it would be for the best interest of every male if he were 
circumcised. In one out of every five male infants circumcision is a 
necessity both for his comfort and his health. In marked degrees of 
phimosis and balanitis, circumcision is the only means of relief. 

An important reason, to my mind, for the operation as a routine 
measure, is that it settles at once and for all time the toilet of the parts. 
The penis after a proper circumcision requires no further manipulation 
on the part of the nurse. The daily retraction of the foreskin and bath- 
ing of the parts is one of the best means of teaching the child self- 
abuse. When this is not done every day or at least every second 
day, trouble is sure to follow sooner or later, in the form of adhesions 
and inflammation of the prepuce. The sensations produced by the 
retraction and the washing are not unpleasant and the child soon 
learns to produce them himself, through leg rubbing, hand pressure, 
or otherwise. (See Masturbation, page 455.) Time and again, after 
having stretched the foreskin and broken up the adhesions, operations 
having been refused, I have had the case return in a few weeks with 
the adhesions and the contractions as bad as before, the nurse or 
mother, timid or neglectful, having failed to follow my directions. 
With phimosis it may require considerable skill to draw the foreskin 
forward after a retraction. It is not always safe to permit the 
attendants to attempt it. Not a few times I have seen a paraphi- 
mosis (page 370) which resulted from an inability to bring forward a 
retracted tight foreskin. 

The dorsal slit, so often practised as a substitute for circumcision, 
is to be used only as a temporary expedient, and as such may be em- 
ployed whenever circumcision is refused. Never, by any means, does 
it take the place of circumcision. It invariably leaves a long, redun- 
dant flap of skin, which easily becomes irritated, causing no little 
discomfort. For the child, it also is a great temptation to mani- 
pulation. 



372 run MAIvK GKNiTAIvS 



GONORRHEA IN THE MALE 

Specific urethritis in male infants and ** runabout" male children 
is a condition seen but rarely, only one case having come under my 
observation. This was in a four-year-old boy whose home was in a 
small tenement and who had been repeatedly exposed through an- 
other member of the family, who, having imbibed the fallacy popular 
among the ignorant, hoped to rid herself of the trouble by giving it to 
the boy! 

The treatment in this case was with irrigation of the urethra with 
a 1 : 10,000 solution of the permanganate of potash. The irrigation 
was used at twelve-hour intervals for two weeks. After four weeks' 
treatment the boy passed from my care, having been placed in an 
institution. During the last two weeks of the treatment the irriga- 
tions were used once daily. There was no further trouble from the 
urethritis. 

ORCHITIS 

Swelling of the testicles is of very infrequent occurrence in the 
young. I have seen but two cases — both complicating mumps. 

The management is rest in bed, saline laxatives, if necessary, and 
support of the inflamed testicles by a wide strip of adhesive plaster 
extending from thigh to thigh. The application of warm sedative 
lotions gives much relief to the pain and discomfort and appears to 
shorten the duration of the attack. Lead and opium solution, U. S. 
P., applied on several layers of gauze and covered with cotton-wool, 
was a satisfactory treatment in the above cases. The dressing 
should be repeated every three hours. After an orchitis a suspensory 
bandage should be worn for several months. 

HYDROCELE 

Hydrocele in the different forms in infants under one year of age 
is frequently seen in children's institutions and in out-patient clinics 
for children. Not a few of these cases have been under treatment 
elsewhere. Drugs, such as the iodid of potash, have been given with 
an idea of absorbing the fluid — a valueless procedure. Some of the 
cases have been aspirated, and to others local counter-irritants have 
been applied. If there is a very large and encysted hydrocele, and 
if the parents are anxious for a speedy cure, aspiration with a hypo- 
dermic syringe may be done, remembering, of course, that the opera- 
tion must be aseptic in every detail. 

In a recent case which came to the out-patient service of the 
New York Polyclinic there had been an aspiration performed. The 
sac became septic and the child died from the infection. 

Not more than one-eighth of the fluid need be withdrawn. 
After the withdrawal of the needle, the site of the puncture 



UNDESCENDED TESTICLE 373 

should be dressed with collodion and aristol, one-half dram of 
aristol to one-half ounce of collodion. I have never found it nec- 
essary to inject into the sac any form of irritant, such as carbolic 
acid or iodin. In fact, fully 98 percent of the cases get well just as 
qmckly without treatment. If the hydrocele is a small one, our 
management at the present time is to let it alone, and spontaneous 
recovery follows in from two to three months. 

UNDESCENDED TESTICLE 

In the normal male at birth both testicles should be in the scro- 
tum. In a considerable number of cases one or both testicles may 
remain in the canal for a varying period, the descent usually taking 
place during the first year. When such descent does not occur, the 
condition may be considered abnormal. It is important not to mis- 
take the condition for hernia and apply a truss. Not a little harm 
may result from such an error. 

A truss should never be used in such a case and operative pro- 
cedures should be delayed until puberty, unless discomfort is ex- 
perienced or disease can be proved. I have known many cases in 
which descent did not take place until the third or fourth year. In 
one case it was as late as the tenth vear. 



THE FEMALE GENITALS 

SIMPLE VULVOVAGINITIS 

In simple vulvovaginitis there is an 'inflammation of the external 
genitals with a secretion of rather viscid mucus. There is moderate 
itching and a burning sensation about the parts — symptoms which 
may resemble those of gonorrheal infection. The cases in which 
there is a purulent discharge are particularly apt to be mistaken for 
gonorrhea. Bacteriologic examination in such cases is the only 
immediate means of differentiating the two diseases. 

Ill-conditioned children and those improperly cared for furnish 
the majority of the vulvovaginitis patients. The disorder is to be 
regarded as one due to a low vitality rather than to a local infection. 

Treatment. — ^Accordingly the management is largely constitu- 
tional : Outdoor life, suitable food, iron and cod-liver oil, are to be ad- 
vised, and, in short, all the measures advocated in the section on Deli- 
cate Children are applicable here. Bathing the genitals twice a day 
with warm water and castile soap, followed by drying with absorbent 
cotton, prepares the parts for a dusting-pow^der which I have found 
useful in these cases. The powder used is of the following composition : 

I^. Acidi borici :gr. xxv 

Pulveris amyli 

Pulveris zinci oxidi aa § ss 

The dryer the inflamed surfaces are kept, the more prompt will be 
the relief, so that if there is a tendency to a free secretion of mucus, 
the powder may be applied at intervals of two hours. 

A convenient means of applying the powder is with an insuffla- 
tor, which may be obtained from any apothecary. After the parts 
are packed with the powder, a dressing of old linen should be applied 
and held in position by a napkin binder. The powder should be re- 
applied often enough to keep the parts dry. 

GONORRHEAL VULVOVAGINITIS 

The disease is seen with great frequency in out-patient work. 
The specific infection is usually furnished by some member of the 
family or by some other infected child. It is readily transmitted by 
sponges, towels, napkins, etc. 

In a typical case there is a profuse, greenish-yellow discharge. 
The parts may be swollen and edematous. The course of the disease 
is most protracted and there is no specific medication which we can 
use locally or otherwise. 

Treatment. — It seems to me, after treating in many different 
ways several hundred of these cases, that keeping the parts clean 
through douching does more toward terminating the disease than 
does the use of any particular disinfectant wash or application. 

374 



GONORRHEAL VULVOVAGINITIS 375 

Douching of the parts is to be practised four times daily, if possible, 
two quarts of water being used. It is useless to attempt the treat- 
ment of a case which cannot be douched at least twice a day. It may 
be remarked that it is a very trying treatment for both patient and 
nurse. Such is certainly the case, but we are deaUng with a disease 
in which strenuous measures only give hope of cure. In order to use 
the douche most effectively, the child is placed on its back on a 
douche-pan. A glass, female catheter attached to a fountain syringe 
is all the apparatus required. The catheter is passed about one-half 
inch within the vaginal orifice and the water allowed to run. The 
lower end of the bag should not hang higher than two feet above the 
child's body. Boric acid is a safe drug in any household. For this 
reason it is selected instead of bichlorid of mercury, permanganate 
of potash or any other antiseptic. I am not at all sure that plain 
boiled water would not answer just as well. It would be difficult, 
however, to persuade many families to use the repeated douching 
without the addition of some antiseptic to the water. Accordingly, 
the mother or nurse is instructed how to prepare two quarts of a 
saturated solution of boric acid. This is used as a cleansing agent. 
After the parts are dried with sterile absorbent cotton, a dusting- 
powder, the formula of which is as follows, is used very freely: 

I^. Acidi borici gr. xxv 

Pulveris amyli 

Pulveris zinci oxidi aa o ss 

The powder is freely dusted into the vagina and over the diseased 
surface after the douche, and at two-hour intervals, during the time 
the child is awake, from early morning to late at night. I tell the 
attendants to pack the parts with the powder. Over this is placed 
absorbent cotton or gauze, which is covered with the napkin. The 
attendants should be warned of the danger of infecting themselves 
and other children in the household with towels, sponges, etc. ; in 
fact, sponges should never be used in these cases. The danger of 
infecting the eyes, not only of the patient but of the attendants and 
others who may come in contact with the case, should be carefully 
explained. When washing or drying is necessary absorbent cotton 
or old linen should be used and immediately burned. A child suf- 
fering from gonorrheal vaginitis should sleep alone. Cheese-cloth 
napkins should be used and burned as soon as soiled. 

A case treated as above may recover in three wxeks, though usu- 
ally from four to eight weeks are required, and in some cases the treat- 
ment must be continued for months. After we have arrived at a 
point where we consider the case cured, there will sometimes be a 
renewal of the discharge and the treatment must be resumed. 

Before the case is finally discharged at least two bacteriologic 
examinations of the vaginal secretion should be made in order to 
determine positively the absence of the gonococcus. 



NERVOUS DISORDERS 

HEADACHE 

A complaint of headache on the part of a child should always re- 
ceive attention. It is unusual in children, and when it is repeatedly 
noted there is generally a good reason for it. 

In children of any age headache may be an early symptom of 
meningitis, particularly of the tuberculous form, in which the head- 
ache may exist for days without other signs of illness. In eye-strain, 
headache is a very prominent symptom, and may be the only evi- 
dence that an ocular defect exists. In persistent headache that 
cannot otherwise be satisfactorily explained I invariably have the 
eyes examined. Headache is often the earliest sign of acute infec- 
tious disease, it being usually a premonitory symptom of scarlet 
fever, measles, or pneumonia. Persistent toxemia from any source 
may be a cause of headache. It may occur in nephritis and in 
malaria. The most usual toxic source, however, is the intestinal 
tract, in which there is generally the association of anemia as well. 
This condition may exist without constipation. Fatigue, as a result 
of overwork at school, or hard play and unusual excitement may be 
a cause of headache in neurotic children. It is frequently encoun- 
tered in girls late in the school-year. Examination of the urine 
may show marked indicanuria. In three cases recently seen by me, 
headache was the only evidence of intestinal derangement. 

Treatment. — ^The management of headache consists in the dis- 
covery and removal of the cause. An ice-bag or an ice-cloth applied 
to the head affords much relief in the acute febrile cases. Ocular 
defects should have the benefit of rest and suitable glasses prescribed 
by an oculist. Fatigue headaches are best controlled by limiting the 
amount of work and providing long periods of rest. Headaches due 
to intestinal toxemia with the usual accompaniment of anemia are 
oftentimes most difficult to relieve. In spite of our best efforts the 
intestinal digestion may remain faulty for a considerable time. A 
change of residence and a radical change in the habits of life are 
usually the best means of effecting a cure. The management of 
these cases is considered in detail under Persistent Intestinal Indi- 
gestion (page 173). 

HYSTERIA 

Hysteria in children is rarely seen before the third year. My 
youngest case was three and one -half years of age when first seen by 

376 



HYSTERIA 377 

me, but the hysterical manifestations had been present for several 
months. Mental, motor, or sensory manifestations may predominate 
in an individual case, although all cases are associated more or less 
directly with an absence of mental control. Girls are much more 
frequently affected than boys, but some of the most typical cases 
coming under my observation have been among the latter. 

We are taught by neurologists that hysteria is almost invariably 
of hereditary origin because of its apparent direct transmission from 
parent to child. It must be remembered that the child, in addition 
to being born of an hysterical mother, is thereafter in constant asso- 
ciation with her. To my mind, in hysteria we have exemplified in the 
most perfect degree the effect of environment. A neurotic hysterical 
mother puts the whole family in a state of high nervous tension. I 
know of several such instances. A neurotic irritable father will 
make the whole family neurotic. I know of such instances also. 
Fortunately for the offspring, both conditions are seldom combined 
in one family. When they are, and I have the children of a few such 
families under my care, the future of the children is discouraging. 
When one of the parents is sufficiently normal to offset a reasonable 
degree of neurosis on the part of the other, a stable equilibrium may 
be maintained. 

Imitation is one of the strongest characteristics of the growing 
child. How often, when arranging with the mother a diet-list for 
one of these nervous, ill-conditioned children, have I heard the 
child say that he "hated" cereals, or "hated" vegetables, or 
"hated" eggs or fowl; or that he "adored" some other article of 
food, this adoration and hatred, particularly the latter, often influ- 
encing the entire future of the child; for without a properly regu- 
lated diet for every day in the year, only an inferior type of adult can 
be the outcome. In such cases it will usualty be found that the likes 
and dislikes of the child are identical with those of the parents, whose 
preference had often been expressed in the presence of the child. 
"Heredity" here furnishes to the parents a satisfactory explanation 
of the child's limitations in diet. It will usually be found that 
parents who live normally have children who eat normally. 

Illnesses and ailments of different kinds should not be discussed 
before nervous and impressionable children. Time and again an in- 
vestigation of a peculiar pain in a child's head, side, or back which 
cannot be accounted for by the physical examination will be ex- 
plained by a similar pain in some older member of the family. 

Illustrative Cases. — In one family I have seen three generations 
of genuine hysteria. In the first generation were the father and 
mother. The father, chronically irritable and neurotic, was a busi- 
ness man with large interests, rarely ceasing, when at home, to talk 
about his ailments and their remedies. The mother had marked 
hysteria. She indulged in frequent attacks, with apparent uncon- 



378 NERVOUS DISORDERS 

sciousness lasting for hours. The daughter, brought up in this 
atmosphere, through heredity and environment soon became 
markedly hysterical. Both she and the mother, when some dispute 
arose in the family, which was not an infrequent occurrence, would 
have simultaneous attacks of hysteria. In due time the daughter 
married and gave birth to a daughter who promises to maintain the 
family traditions with certain additions of her own. 

I have under my care a girl seven years of age who is in deadly 
fear of appendicitis and develops an attack of hysteria every time she 
has a pain. She can locate ''McBurney's point" and knows the 
various stages in the development of the disease and the steps in the 
operation for appendicitis. The mother's appendix, suitably pre- 
served, is among the family relics, whence it cannot be removed. 
The influence of heredity has perhaps had the effect of making the 
child alert, precocious, and impressionable, and such favorable soil 
and the constant association with the hysterical will almost surely 
develop hysteria in a child. 

Treatment. — General. — My results with hysterical children have 
usually been very good or very poor, depending to a great extent 
upon my ability to separate the child from its family, by this state- 
ment the management of hysterical children is suggested. Re- 
move the child, if possible, from the unfavorable family influence. 
The boarding-school has effectually cured several of my cases. Here 
the child is placed under the care of trained minds, teachers who 
bring out the good and correct the bad by reason, precept, and 
example, and who thus exert a continuous, beneficial influence. In 
the boarding-school, plain diet, pleasant occupation, agreeable asso- 
ciation, and a scientifically regulated life replace the spoiling and 
coddling and oftentimes the unsuitable food, together with the end- 
less nagging which the neurotic mother is very apt to indulge in, 
with the best intentions, of course, but nevertheless with a most 
unfortunate effect upon the child. If the child is too young for a 
boarding-school or if admission is denied him, he should be placed 
under the care of some kindly, well-balanced woman as companion 
and instructor, and see as little of his family as possible, otherwise 
but little can be expected from the treatment. Of course, the con- 
ditions must be explained fully to the parents in order that they 
may make an effort in the right direction as to their bearing toward 
the child. If the former conditions as to intimate association with 
the child continue, the good intentions, according to my observation, 
may last only a very few days. It is impossible to reform the habits 
of life of a neurotic adult. If he has grown that way, that way he 
will remain. The only hope for the child is in his complete removal 
from such unfavorable influences. 

The further treatment of hysterical children consists in curtail- 
ing the mental and ph^^sical activities, which almost invariably 



HYSTERIA 379 

have been excessive. A rational scheme of Uving should be formu- 
lated. "Showing off" the child to visitors and others should be 
forbidden. If under ten years of age, he should retire at seven 
o'clock every night and rise at seven every morning. It is under- 
stood by the attendant that this does not mean 6.45 or 7.15. 
Every day after the midda}^ feeding, the child should rest quietly 
in a darkened room for an hour or two. Whether he sleeps or not, 
he rests in a recumbent position with clothing removed. For 
such children exciting games of stress and competition of every 
nature are forbidden. An outdoor Hfe is encouraged. A bicycle, a 
pony, an individual play-room in winter and a tent on the lawn in 
summer should be provided when possible. School instruction may 
be given, but the child is not to be crowded. The amount of study 
and work depends, of course, upon the child's condition. Until the 
tenth 3^ear, however, there should be but one morning session, of 
from one and one-half to three hours. The child is given a tub -bath 
or brine bath daily at 90° F. (page 31); at the completion of the 
bath he stands with his feet in warm water and is given a cool douche, 
at 60° to 70° F. , the spray tube being attached to a faucet ; or cold 
water may be poured down the spine. The application of cold water 
should be for a few seconds only and should be followed by a brisk 
rubbing with a rough towel, which should result in a decided skin 
reaction. 

Treatment During Hysterical Seizure. — During a hysterical seiz- 
ure the child should be treated with kindness but with firmness. No 
sympathy should be shown. The application of ice-water to the 
face and chest is usually sufficient to break up an attack. In some 
cases a certain amount of time appears to be required for a return to 
the normal. 

Drugs. — Sedative drugs, such as the bromids, should not be used. 
Cases have come under my observation showing the bromid rash. 
Such treatment, as also the use of the opium derivatives, cannot be 
too strongly condemned. Drugs that increase the appetite and im- 
prove nutrition should be given. I have found that iron and arsenic 
answer well in these cases, as most of the patients show a secondary 
anemia. For a child from five to ten years of age the following 
prescription has been useful : 

I^. Liquoris potassii arsenitis gtt. xc 

Extract! f erri pomati gr. x 

Quininae bisulphatis gr. Ix 

M. div. et ft. capsulae No. xxx. 

Sig. — Take one after each meal. 

If constipation results from the use of the small doses of iron, one- 
third to one-half grain of the extract of cascara may be added to each 
capsule. If the child cannot swallow a capsule the following may be 
used- 



380 NBRVOUS DISORDERS 

I^. Liquoris potassii arsenitis gtt. Ixxij 

Ferri et ammonise citratis gr, xxiv 

Elixiris simplicis §ss 

Aquae q. s. ad §iv 

M. 

Sig. — One teaspoonful after each meal in a glass of water. 

The iron and arsenic may advantageously be alternated with pure 
cod-liver oil — one to two drams after meals — each being given for 
seven days. Alcohol should form no part of the medication of these 
children. In using the so-called liquid proprietary foods, it is to be 
remembered that some of them contain a considerable percentage of 
alcohol. 

INFANTILE CONVULSIONS 

Convulsions in the newly born are usually of an entirely different 
nature from those which occur after the third month. During the 
early days of life, a convulsion is always a matter of serious import, 
as it frequently is the result of a birth trauma and suggests a possibly 
serious brain lesion, which may terminate in early death or result in 
spastic paralysis or idiocy or both. 

An appreciation of the causes of convulsions in older infants and in 
young children suggests the treatment. The predisposing causes are 
rachitis and other forms of malnutrition. While the rachitic child is 
particularly susceptible, the most vigorous is by no means exempt if 
the exciting cause is of a sufficient degree of severity. Uremic con- 
vulsions (page 361) are always preceded by evident kidney involve- 
ment, which may at once explain the cause of the seizure. The 
cause in at least 90 percent of the cases is an irritation within the 
gastro-enteric tract, due to a foreign body or undigested food, or 
the absorption into the circulation of toxins — the products of decom- 
position in the intestinal contents. In two of my patients phimosis 
with much smegma and irritation was the most plausible cause of the 
convulsions. Both had had several convulsions, which were not re- 
peated after circumcision was performed. In a small percentage 
of the cases convulsions are the earliest manifestations of lobar pneu- 
monia and scarlet fever. In fact, a convulsion may be a prodromal 
symptom of any of the infectious diseases. One of my patients had 
repeated convulsions until he was relieved of forty-three large round- 
worms. So frequently is intestinal toxemia a cause that when a 
child in apparent health is seized with a convulsion, it is safe to 
assume that it is of gastro-enteric origin ; if such should not be the 
case, the treatment directed toward relieving the digestive tract is 
always advantageous, even if the convulsion is the first symptom of 
lobar pneumonia or meningitis. 

Treatment. — ^When a convulsion occurs, the patient should at 
once be undressed and placed in a warm mustard bath (page 30) 
at a temperature of 105° F. While in the bath, there should be 
a brisk friction of the trunk and extremities, particularly the latter. 



INFANTILK CONVULSIONS 38 1 

At the same time an attendant may give an injection of soap-water. 
In a great majority of the cases, in less than five minutes the child 
will show evidence of a return to consciousness. As soon as he can 
swallow, two teaspoonfuls of castor oil should be given. After a 
seizure the patient should be kept very quiet for twenty-four or 
forty-eight hours. An ice-bag or cold cloths should be applied to 
the head and a guarded hot- water bottle kept at the feet. The diet 
should be of the Hghtest. Chicken broth, weak beef -tea or chicken- 
tea, and thin gruels should constitute the nourishment for a day or 
two. A second seizure is more easily produced than the first, and a 
third easier than the second, and as about 10 percent of the cases 
of epilepsy are the outcome of infantile convulsions, it is the physi- 
cian's duty to see to it that the indiscretion in diet which caused 
the first attack is not repeated. 

In case the attack is a very severe one, when the child is slow to 
respond or when he passes rapidly from one convulsion to another, 
chloroform inhalations, regardless of the age, should be given in suffi- 
cient quantity to prevent the seizures until the intestinal canal can 
be emptied and sufficient sodium bromid and chloral can be given by 
mouth or rectum to prevent a recurrence. For a child under one 
year of age, eight grains of sodium bromid and three grains of 
chloral may be given by rectum in two ounces of mucilage of acacia. 
After the first year, from three to five grains of chloral may be given 
with from ten to twenty grains of sodium bromid. It is best to 
attach to the syringe a soft-rubber catheter, No. 18 American, or 
a small rectal tube. The catheter should be introduced for at least 
nine inches, so that the solution may be carried to the descending 
colon, where it will better be retained than if introduced w^ith the 
small hard-rubber tip simply within the anus. The bromid and 
chloral may be repeated at intervals of from two to six hours, as 
required to control the convulsions, and continued in diminished 
doses as long as there are noticeable signs of ner\"ous irritability, 
such as twitching and involuntary muscular contractions. If the 
child can swallow, five grains of sodium bromid, in one-half ounce of 
water, may be given, and repeated at intervals of from one to four 
hours, until the convulsions are controlled. Morphin hypoder- 
matically is rarely required. It should be used only when other 
measures fail. A child one year of age may be given 3-^^ grain, which 
may be repeated in two hours, though usually it will not be necessary. 
Under one year -^ to -j--^ grain may be given; under six months, 
morphin would better be omitted. 

Convulsions should never be lightly regarded. They may be seri- 
ous in their immediate as well as in their remote possibilities. One 
convulsion may produce cerebral hemorrhage which may change the 
entire future of the patient, producing spastic paralysis or idiocy, 
or both. About lo percent of the cases of epilepsy originate in indi- 



382 NKRVOUS DISORDERS 

gestion — the so-called "dentition convulsions." In these, rachitis 
plays an important etiologic part. It is the duty of the physician, in 
a given case, to ascertain the cause and so direct the future manage- 
ment of the patient as to avoid a recurrence of the attack. 

Under my observation several children under one year of age, in 
apparently good health, have died of convulsions. In one we found 
at autopsy one-eighth of an orange in the small intestine. In six, 
the convulsions were due to enlarged thymus glands. In three of 
these cases there were no previous symptoms of the existence of this 
condition (page 471). They were strong robust infants. Two of 
them were breast-fed. The diagnosis was confirmed by autopsy in 
four, which included the breast-fed. 

NIGHT-TERRORS 

In night-terrors the child arouses from his sleep frightened, and 
sometimes imagines that animals or persons are trying to injure him. 
In a great majority of cases these phenomena are due to a deranged 
digestion in a neurotic child. The attacks are very liable to follow 
indulgence in unusual articles of diet, and when they occur repeatedly, 
it will usually be found that the child is suffering from persistent 
intestinal indigestion or that the evening meal is habitually beyond 
his digestive capacity. Children subject to night-terrors should 
dine at midday. The evening meal should consist of cereals, milk, 
stale bread and butter, and a small portion of stewed fruit. The 
patient should never be allowed to go to bed unless an evacuation 
of the bowels has taken place during the previous twenty-four hours. 

Overwork at school and anxiety regarding school duties and 
lessons are often contributory factors to night-terrors. The cases 
usually are readily relieved by proper treatment. If the case is 
an aggravated one, the child should be removed from school, and all 
exciting play and books of an exciting nature forbidden. 

One of my patients, a boy who was four years of age when he 
first came under my care, has had, during the past five years, two 
attacks of night-terrors every year. One attack occurs on the night 
of his birthday and the other on Christmas night. At these times, in 
spite of my warnings and the repeated attacks, he is indulged by 
his parents in unsuitable articles of food. 

In the very nervous and irritable cases from five to ten grains 
of bromid of soda may be given at bedtime. This should not be 
continued longer than a week. If the child is delicate, anemic, 
or suffering from adenoids, enlarged tonsils, or thread-worms, these 
conditions, any one of which may contribute to night-terrors, should 
receive proper treatment. 

GYROSP ASM— SPASMUS NUTANS 
Gyrospasm is a functional nervous affection usually seen in chil- 
dren under one year of age. I have seen one case in a child fourteen 



TETANY 383 

months of age. The disorder consists in a rotatory movement of 
the head, sometimes from twenty to forty oscillations being made 
in a minute. The movement may not only be lateral but vertical 
also, which constitutes what is known as "head-nodding." In 
one of my patients both the lateral and the vertical movements 
took place. The oscillations are usually, but not invariably, asso- 
ciated with nystagmus. I have seen a number of these cases in 
out-patient clinics. Rachitis was present in all. Two of the children 
were idiots. 

The prognosis is good if the patient is mentally normal. It 
is difficult to state the length of time required before the move- 
ments will cease. It is doubtless a matter of several months. With 
a disorder essentially chronic in character, the improvement is slow. 
The mother becomes dissatisfied with the treatment and wanders 
from cHnic to cHnic with her child. This probably explains in part 
the large number of individual cases seen by pediatrists. I have 
had the opportunity to give a few cases a fair trial with sodium 
bromid — from twelve to eighteen grains daily — a treatment which 
is generally advocated for this condition, but have failed to note 
any special benefit from its use. With an increase in age and im- 
provement in nutrition, the cases which I have followed at their 
homes have gradually improved and recovered. 

TETANY 
Tetany occurs oftentimes in association with or following ex- 
haustive diseases. It may occur, however, without any such rela- 
tion to other affections. In my cases there have invariably been 
rachitis, malnutrition, and intestinal indigestion of a pronounced 
type. The muscular spasms may involve any portion of the body, 
but the extremities are most frequently affected. 

Treatment. — Inasmuch as intestinal toxemia and malnutrition 
are the apparent causes of the phenomena, attention directed to the 
intestinal canal and nutrition is indicated. The child should be 
given two drams of castor oil, and milk should be excluded from 
the diet for a day or two until the stools become normal. This 
treatment alone has cleared up some of my cases. When the spasm 
persists, bromid of soda should be given in two-grain doses every 
two hours, giving at least six doses in twenty-four hours, for a child 
one year of age or younger. The patient should be kept very quiet 
during an attack, as undue excitement may precipitate an attack 
of laryngismus stridulus or convulsions which may be of a very 
serious nature. A hot bath at 110° F. for a few moments, and 
repeated at six-hour intervals, will often have the desired relax- 
ing effect. 

The later treatment consists in regulating the child's nutri- 
tion. If the malnutrition is extreme or if the infant is under six 



384 NKRVOUS DISORDERS 

months of age a wet-nurse is the safest means of nutrition. A 
wet-nurse, however, is not practicable in children beyond one year 
of age. There is considerable uncertainty as to how these older 
children, those approaching the twelfth month, will take the 
breast. When the wet-nurse is impossible or impracticable, an 
adjustment of the food to the child's digestive capacity is demanded 
along the lines laid down in the section on Malnutrition. 

Not a few of the infants who develop tetany have been on a 
low proteid such as is furnished by the proprietary foods and con- 
densed milk, or they may have had a low proteid capacity, which, 
as far as the nutrition is concerned, is practically the same thing. 
The proteid elements in the diet, therefore, should be kept well in 
mind in feeding these cases. It is in such cases that peptonized 
milk (page 119) is indicated. The milk should always be given 
raw unless the station in life or season of the year forbids it. 

When it is possible, children who have had tetany should 
in every instance be given the advantages furnished by climate. 
An outdoor life in the country with open windows at night 
are necessary for rapid reUef of the weakened physical condi- 
tion which underlies the disorder. The patient should be given 
a brine bath (page 31) at bedtime. It is followed by inunc- 
tion with an animal fat during the cooler months, goose oil being 
preferred. As these patients are usually suffering from a secondary 
anemia, one-half grain of the citrate of iron and ammonium may be 
given twice or three times daily after feeding. The hygienic and 
dietetic management of these cases is practically the same as that 
suggested for marasmus and malnutrition. 

CHOREA— ST. VITUS^ DANCE 

The management of chorea depends entirely upon the degree 
of severity of the attack. It may be necessary in extreme cases 
to keep the child in bed from three to four weeks. In other cases, 
where the attack is milder in character, the enforced rest may do 
harm. Formerly I treated more cases on the extreme rest plan 
than I do at present. For cases in which the involuntary move- 
ments are so marked as to interfere with locomotion and prevent 
the child's feeding himself, rest in bed for a week or two is strongly 
advised. In my observation, it is mental repose which the patients 
particularly require, and if this can best be obtained in bed, 
then the bed is the best place for the patient. If an absence of 
mental excitement and stimulation can be secured with a reason- 
able amount of outdoor life and exercise, so much the better for 
the patient. An important feature to be remembered in the manage- 
ment of choreic children is that they must not be allowed to become 
fatigued either physically or mentally. 

In the cases which have been confined to the bed for several 



CHORKA — ^ST. VITUS' DANCE 385 

days or weeks, a gradual return to the usual habits is best. The 
child should be taken up for one-half hour the first day, increasing 
the time out of bed one-half hour daily, until he returns to his usual 
habits of life. School for the choreic patient is out of the question, 
no matter how mild the case. In the great majority of cases, play 
with other children will have to be interdicted. Books and play 
of an exciting nature are particularly to be avoided. Specific 
instructions as to the amount of physical and mental rest required 
cannot be given so as to apply generally in the management of 
chorea. The physician should particularly remember that there 
must be no bodily fatigue and no mental stimulation of any nature 
whatever. How best to bring this about will depend upon the 
child and his environment. 

In two instances I have been obliged to remove the child from 
his home and place it among relatives. The influence of the mother 
was such as hopelessly to prevent the child's recovery. Cases 
not sufficiently severe for confinement in bed, should be made to 
rest for two hours every day after dinner. 

Striimpell in his text-book states that the association of chorea 
and rheumatism is so close that it is impossible to separate them. 
Hirt, in discussing nervous diseases, expresses the view that there 
is a common toxic etiologic factor which, affecting the cortex, pro- 
duces chorea; but affecting the joints, gives rise to acute articular 
rheumatism. That the association of chorea and rheumatism is 
a most intimate one, has been borne out by the observations of 
many clinicians. A trifle over 50 percent of my cases of chorea 
either gave a history of having shown rheumatic manifestations, 
or they showed evidence of it when first seen. In 80 percent of my 
cases there was some association with rheumatism, either in rheumatic 
parents or in the actual manifestations of rheumatism at some time 
in the patient's life. So impressed have I been by the above facts, 
and by the similarity of the clinical signs of these supposedly distinct 
diseases, that I believe them due to the same toxic agent. This 
is further proved by the results of treatment. 

Anti-rheumatic Treatment. — By treating every case of chorea 
as though it were rheumatism, my results have been strikingly 
better. Not only is the child given the salicylates, but he is 
put on an ant i- rheumatic diet — given meat but once every sec- 
ond day, and but little sugar. The salicylate of soda may be given 
in smaller doses than are used in acute articular rheumatism — about 
five grains three times daily, with an equal amount of the bicar- 
bonate of soda, being suitable for a child from six to ten years of 
age, the soda being given between meals. To children of this age 
the salicylate may be given either in capsule or in solution. In 
young children, the drugs in solution are more easily administered. 
During the past year I have given aspirin to a few patients in whom 
25 



386 NERVOUS DISORDERS 

the digestive functions were weak or who could not take the saU- 
cylate of soda. In using the saHcylate of soda, Merck's or Squibb's 
preparation should always be indicated. In using salicylate of 
soda or aspirin for a considerable time, it is well to remember that 
they may interfere with the appetite and digestion, no matter how 
great the care exercised in their use. For this reason it is my custom 
to give them intermittently — five days of medication being fol- 
lowed by five days of rest. 

I have found that by putting the patient on the anti-rheumatic 
treatment much less arsenic is required, and that the patient usually 
makes a more prompt recovery. I have never been obliged to resort 
to the large dosage of twenty-five to thirty drops of Fowler's solution 
three times a day, as suggested by Seguin. It is exceedingly rare 
that it is necessary to give more than ten drops three times daily 
in order to procure satisfactory results. In spite of the value of 
the anti-rheumatic treatment this alone will not answer, as I have 
proved to my satisfaction in not a few cases. The administration 
of the arsenic and the salicylate and the dietetic regime are begun 
at the same time. The salicylate of soda is given at once at the 
commencement of the treatment in as full doses as we expect to 
give it. Arsenic is commenced in small doses, which are grad- 
ually increased in order to establish a tolerance of the drug. Fowler's 
solution of arsenic is usually employed. In order that no error 
be made in its administration, a table similar to the following is 
given to the mother or attendant. For a child six years of age 
on the first day after each meal, two drops should be given as indi- 
cated below. Thereafter, the dosage is increased by one drop every 
twenty-four hours, according to the following schedule : 

DOSAGE OE EOWEER'S SOLUTION EOR A CHILD SIX YEARS OLD 

1st day — Morning, 2 Drops. Noon, 2 Drops, Night, 2 Drops 

2d "' " 2 " "2 " " 3 

3d " " 2 " " 3 " "3 

4th " " 3 " "3 " " 3 

This rate of daily increase is continued up to the third week, 
after which time the dosage should range from five to ten drops 
three times a day. For a child of eight to ten years of age the 
amount may be increased to twelve to fifteen drops three times a 
day. I have never found it necessary to give more than twelve- 
drop doses to girls of thirteen to sixteen years old. A very recent 
aggravated case in a girl fifteen years of age made a complete recovery 
in three weeks under the above scheme of diet, the use of aspirin, 
ten grains three times daily after meals, and Fowler's solution up 
to twelve drops after each meal. With the improvement of the 
case, the diet should be continued. The medication may gradu- 
ally be reduced after all the symptoms have disappeared. It should 



HABIT SPASM TIC 387 

be continued, however, in from one-third to one-half the quantity, 
for three weeks after the disappearance of all nervous symptoms. 

Supplementary Treatment. — It should be remembered that 
children who have once had chorea are very susceptible to recur- 
rent attacks. This is also the case with children who have had 
rheumatism. After one attack of chorea the danger of a return is 
explained to the mother, who is asked to bring the child for exami- 
nation at the first suggestion of involuntary muscular twitching. 
In addition to this, children who have had chorea, as well as those 
w^ho have had rheumatism, are allowed meat but once every second 
day, and in no case is an excessive use of sugar permitted. Candy 
is usually forbidden. Believing that these cases are rheumatic in 
origin, when the attack is over I order the child to receive ten grains 
of bicarbonate of soda daily for five days out of every fifteen. In 
this way, with a reasonably quiet home life and no school contests 
for prizes, etc., a recurrence will in all probability be prevented. In 
giving arsenic, mothers are advised that in the event of abdominal 
pain, diarrhea, coated tongue, foul breath, vomiting, or pufhness 
under the eyes, the drug is to be discontinued for at least two 
days. Upon resuming it, the minimum dose is again given with 
the same gradual increase. 

Children vary greatly as to their tolerance of arsenic. A boy 
seven years old, under my care at the present time, cannot take 
more than four drops of Fowler's solution three times a day. 

HABIT SPASM— TIC 1 

By habit spasm we understand a semi-incoordinate movement 
of some portion of the body. The term ''semi-incoordinate" is 
used advisedly, because the spasm may be controlled when the 
child's attention is directed to it, this being one of its distinguish- 
ing features. The muscles involved in the spasm are usually those 
of the head, face, or arm. The nose may be drawn up, the chin 
down, or the head to either side. The muscular spasm is worse 
when the patient is tired and occurs more frequently under excite- 
ment. While these children cannot be said to have chorea, there 
is a close association of the two conditions, there being but a step 
from habit spasm to true chorea. Habit spasm is most frequently 
seen in those of rheumatic inheritance — those who have had previ- 
ous attacks of chorea or rheumatism or the respiratory manifes- 
tations so frequently seen in children of the rheumatic type. 

Treatment. — The management is dietetic, hygienic, and medi- 
cinal. I allow these patients a small portion of red meat once a 
day. Sugar is given in sufficient amount to make the food pala- 

^ Dr. Edward Wheeler Scripture, in his treatment of tics, has his patients 
stand in front of a mirror and imitate the tic, thus converting it from an invol- 
untary to a volitional one. By this means he shows surprisingly prompt and 
favorable results, especially when the tic is of recent contraction. 



388 NERVOUS DISORDERS 

table. The vegetable and legume element in the diet is made 
prominent. The patient will usually be found poorly nourished, 
often he is suffering from a secondary anemia, so that a diet best 
calculated to improve his general condition should be prescribed. 
He should be given a salt bath (page 31) at bedtime, followed by 
an oil rub — one ounce of goose oil, unsalted lard, or olive oil being 
rubbed into the skin immediately after the bath. 

Temporary absence from school or a lightening of school duties 
and an outdoor life are of much aid in the successful management 
of a case. The child should not be allowed to do anything of a 
strenuous nature. Hard play and any amusements of an exciting 
character are to be forbidden. Fatigue must be avoided. Rest 
after the noon-day meal for an hour or two is strongly recommended. 

As to medication, the scheme suggested for chorea is also appli- 
cable here. If there is anemia, iron is given, preferably in the form of 
the extractum ferri pomatum, J grain three times a day. In those 
children who cannot take cream or butter, cod-liver oil in teaspoonful 
doses is a valuable addition to the treatment. The iron may be 
alternated with the cod-liver oil, each being given for five days. 
If there is a rheumatic history or inheritance, aspirin or salicylate 
of soda, preferably aspirin, is given in capsule with the iron. The 
following is a favorite prescription for a child five years of age: 

I^. Liquoris potassii arsenitis gtt. iij 

Extract! ferri pomatum gr. ss 

Aspirin gr. iij 

Sig. — One dose ; to be given in capsule after each meal. 

The use of arsenic, while of advantage, does not appear to be as 
valuable here as in chorea. 

Habit spasm being practically under the control of the will, 
should be strictly forbidden, rewards being given and punishments 
imposed, as seem to answer best. 

EPILEPSY 

While the underlying conditions as regards the pathology and 
etiology of epilepsy are better understood as a result of the study 
which has been devoted to the subject during the past few years, 
our knowledge as to the successful treatment of the disease has not 
increased materially, if we are to judge from the recent writings 
of the best authors. While appreciating the value of workers in 
this field, I am sure that there is a disposition on the part of some 
writers to draw too narrow lines of differentiation between different 
types of the disease. 

Treatment. — In the management of epilepsy we can promise little 
or nothing as to cure, and practically all we can hope to do is to 
diminish the frequency of the attacks which characterize the dis- 
ease, whether it be a grand mal or a petit mal. Proper nutrition. 



EPILEPSY 389 

rational habits of living, and pleasant outdoor occupations are of 
inestimable service in the management of the epileptic. The 
method of management which has served me best has been, first, 
along general and hygienic lines ; and, second, by the use of drugs. 
It should be our object to make the patient physically as normal, 
as vigorous, and as resistant to attacks as lies in our power. 

Visual defects, enlarged tonsils, adenoids, phimosis, and irritant 
skin lesions must all be corrected before beneficial results are to 
be expected from any Hne of treatment. The patient is then 
placed under the best possible environment permitted by his station 
in life. Outdoor life, sports, and games are encouraged, always 
keeping within the lines of moderation. The child should sleep 
in a cool room with the freest possible ventilation at all seasons of 
the year. If he is a school-child, he is instructed at home and the 
sessions are made short and the studies easy. The patient in his 
work or play is never allowed to reach the point of mental or 
physical fatigue. This, to my mind, is most important. Emotional 
plays at the theater and exciting amusements elsewhere are forbid- 
den. 

The diet is to be adjusted to the child's digestive capacity. A 
diet suitable for his age is given, just as for normal children (page 
134), meat being allowed only once a day. As intestinal indigestion 
and toxemias from intestinal sources are unquestionably important 
etiologic factors in not a few cases in causing a recurrence of the 
seizures, careful attention to the bowel function and diet are most 
important features of the treatment. The epileptic patient under 
my care is never allowed to pass over twenty-four hours without an 
evacuation of the bowels, and if, in the opinion of those in charge, 
it is not as copious as usual, an enema is given. If there is a sug- 
gestion of constipation, the treatment with the oil enemata, as re- 
commended for chronic constipation (page 178), is instituted. In 
cases in which heredity and toxic influences prevail, the im- 
portance of attention to the diet and habits of life cannot be 
overestimated. AVhen there is a focal lesion, attention to the details 
of living will have less influence, but always surely some influence, 
in diminishing the frequency and severity of the seizures by es- 
tablishing a more vigorous physical resistance. 

Among those who are unable to give the patient suitable atten- 
tion at home I urge that he be placed in one of the excellent insti- 
tutions devoted to the care of epileptics. The colony management 
offers advantages that cannot be secured elsewhere. Here the 
whole manner of life is adjusted and regulated with one object in 
view. 

There are few drugs in the pharmacopeia, particularly those 
of a sedative nature, that have not been used at one time or 
another in the treatment of epilepsy. The bromids unquestionably 



390 NKRVOUS DISORDERS 

serve our purpose in controlling the seizures better than does any 
other form of medication. The size of the dose is variable. Because 
of their peculiarly depressing effects upon the child's mental con- 
dition, the bromids should be given in as small quantities as are 
compatible with the beneficial results desired — a diminution of the 
number of the convulsions. Ordinarily ten grains of sodium bromid 
may be given, well diluted, in one-half glass of water after meals, 
to a child ten years old, the amount to be increased or diminished as 
the progress of the case demands. If the convulsions are nocturnal, 
large doses — from twenty to thirty grains — should be given at bed- 
time to a child of ten years. In the event of the drug being discon- 
tinued to the point where it is given but once a day, the time 
selected should be bedtime c With continued improvement under 
the bromid, it may be given on alternate nights, and then every 
fourth night. 

Illustrative Case. — I have now under my care a case which 
I have treated for several years and which promises well. The 
first convulsion occurred at the fifteenth year. It was a typical 
nocturnal seizure. Fifteen grains of bromid with five drops of the 
tincture of belladonna were given three times daily for three months, 
when the amount was reduced to thirty grains daily. This was 
continued for one month, when a death occurred in the family 
which doubtless helped to incite a second attack. At this time, 
the patellar reflex being scarcely perceptible and the bromid rash 
considerable, the drug was discontinued. At the end of two months 
the daily dosage was placed at twenty grains, with ten drops of 
the tincture of belladonna. This was continued for four weeks, 
when there was a third attack, without any apparent cause of an 
exciting nature, but the patient had allowed herself to become obsti- 
nately constipated. This was her last attack. Three years have 
since intervened. The bromid has been gradually reduced, first 
to ten grains daily at bedtime, then every other day, and now it 
is taken every fourth day only. 

ACUTE SIMPLE MENINGITIS 
The Management of Acute Simple Meningitis. — This form 
of meningitis is almost always secondary to disease elsewhere, 
and may be due to many different kinds of micro-organisms, the 
most usual being the pneumococcus, streptococcus, staphylococcus, 
and colon bacillus. The most one can do in acute simple meningitis 
is to nourish the patient and lessen his discomfort. Proved cases 
rarely recover. We have no means of treatment that may be con- 
sidered curative in any sense. By the use of repeated lumbar punc- 
ture we can in some cases make the patient more comfortable and 
perhaps aid him to resist the infection. The pulse and the respira- 
tion improve as well as the urgency of the nervous phenomena; the 



ACUTE SIMPLE MENINGITIS 39 1 

Opisthotonos and the excessive hyperesthesia may be temporarily 
reheved. There is no rational ground for expecting the withdrawal 
of the cerebrospinal fluid to be curative, neither may the injection 
of disinfectant drugs into the canal be expected to aid in controlling 
the disease. 

Lumbar Puncture. — Lumbar puncture (page 396) may be prac- 
ticed as frequently as once in twenty-four hours, the frequency of 
its use depending, of course, upon the condition of the patient and 
the rehef afforded. Its more frequent use than once in twenty-four 
hours, as has been suggested by some writers, is not, however, to be 
advised. The amount of fluid withdrawn depends upon the pressure 
in the canal as indicated by the passage of fluid through the canula, 
from one to three ounces being the usual amount withdrawn. The 
usual surgical precautions as regards asepsis should be observed in 
performing the operation. One dram of aristol in one ounce of col- 
lodion, applied with a camel's-hair brush, makes a suitable protective 
dressing after the withdrawal of the canula. 

Warm Packs. — The warm pack or warm bath at 105° F., by less- 
ening the cerebral blood-pressure, may also assist in relieving the 
more active nervous manifestations. If the bath is used, the child 
should not be kept in it longer than three minutes. I usually pre- 
fer the hot pack. A large bath towel or medium-weight flannel sheet 
is wrung out of water at 110° F. and wrapped around the child's body 
from the waist down. This is repeated at half -hour intervals for 
three hours, when, after a period of rest for an hour or two, the 
packs may be resumed. 

Diet. — The proper nutrition of the patient with meningitis is 
oftentimes a matter of no little difflculty. The child may either 
refuse the food or he may be unable to swallow. Nutrition by means 
of the rectum or colon may be of assistance for a few days, but it can- 
not be relied upon for long periods. The parts become intolerant 
and the nutrient enemata are expelled. Feeding by means of gavage 
is alwa^^s to be employed when other means fail. The younger the 
child, the greater will be our success with it. The feeding should 
not be attempted oftener than at four-hour intervals; usually every 
six hours suflices. Completely peptonized full milk (page 120) is usu- 
alh^ given in quantities suitable for the age. After a few trials of 
gavage, the patient may take the nourishment by the usual method 
or the gavage may be kept up indefinitely. 

Sedatives. — Sedatives may be employed with a view to saving 
the strength of the patient. Morphin, codein, the bromid of soda, 
or chloral may be given. As morphin and codein increase the usual 
existing constipation, their use should be ver}' temporary. The 
bromid of soda for these cases, which may require the protracted ad- 
ministration of a sedative, answers better than any other form of 
medication. For an infant under eighteen months of age, from two 



392 NKRVOUS DISORDERS 

to four grains may be given at intervals of two to three hours, 
according to the results. In case the nervous symptoms are very 
urgent, one-half to one grain of chloral may be added. Should ad- 
ministration by mouth be impracticable, the sedative may be given 
by rectum, and should be introduced by means of a rectal tube in- 
serted at least nine inches. In using the bromid and chloral in this 
way, twice the amount of chloral and thrice the amount of bromid 
should be given that is employed in stomach administration. After 
the eighteenth month, from one to two grains of chloral and from 
four to eight grains of the bromid may be given by stomach. It 
should be well diluted and repeated as often as may be necessary. 
In case it is to be given by rectum, it should be diluted with at least 
four ounces of water, and proportionately more given, as suggested 
for younger children. 

The duration of illness of this type of meningitis is rarely longer 
than two weeks. Following as it does diseased processes elsewhere, 
it usually finds the child with very little resistance to offer the fresh 
invasion. 

CEREBROSPINAL MENINGITIS 

When the medical history of the nineteenth century is written, 
the years of 1907 and 1908 will stand out prominently as marking 
the epoch when cerebrospinal meningitis first felt the master hand. 
Until within a few months we have stood as helplessly by the bedside 
of a patient ill with cerebrospinal meningitis as we now do beside 
the tuberculous form. To the genius of Dr. Simon Flexner is due the 
elaboration of a serum which shows results in the treatment of this 
disease which, to say the least, are most gratifying. Dr. Flexner, 
in the Journal of the American Medical Association, vol. li., No. 4, 
presents an analysis of 400 cases treated with antimeningitis serum. 
The serum is prepared in the horse by inoculations of the diplococcus 
intracellularis and its products. 

In the 400 cases the diagnosis had been established by bacterio- 
logic examinations. In arranging the records or the observations 
account was taken of the age of each patient, the period of the 
disease when the serum was first injected, the number of injections 
made, the dosage of the serum, the effects on the temperature, and 
the subjective and objective symptoms of the disease, on the number 
and viability of the diplococci in the spinal exudation, the general 
leukocytes, the duration of the fever, and the manner of recpvery, 
whether by crisis or by lysis. All cases which survived the first dose 
of the serum less than twenty-four hours were excluded, as marked 
beneficial effects could not be expected in so short a period. 

Results According to Age of Patient.^ — Total number tabulated, 
393. Recoveries, 295. Deaths, 98. Seventy-five percent recovered 
and in 25 percent the issue was fatal. In the following table Dr. 



CKRKBROSPINAL MENINGITIS 393 

Flexner gives the relation between the recoveries and the ages of the 
patients : 

P'-^t^-t- numbt. R--ered. Died. ^--nt^of 

Under i year 22 11 1 1 50.0 

Between i and 2 years 19 1 1 8 42.1 

Between 2 and 5 years 68 52 16 23.5 

Between 5 and 10 years 79 70 9 1 1.4 

Between 10 and 20 years 105 80 25 23.8 

Over 20 years 87 64 23 26.4 

Age not given 13 7 6 46.1 

Results According to Period of Injection.— Among 328 cases 
the histories were sufficiently explicit to make it possible to approxi- 
mate the period in which the first serum injection was made : 

Period of injection of serum. ^p"den[s°^ Recovered. Died. ^de'aths°^ 

First to third day 121 103 18 14.9 

Fourth to seventh day 100 78 22 22.0 

ivater than seventh day 107 68 39 36.4 

It would seem from the table that while the cases injected early 
have the best opportunity for recovery, nevertheless, as some were 
injected after days and weeks of illness, it would appear that the use- 
fulness of the serum did not cease as long as the diplococcus was 
present in the cerebrospinal fluid. 

Manner of Termination. — In 270 cases Dr. Flexner was able to 
determine whether the termination was by lysis or crisis; 201 termi- 
nated by lysis and 69 by crisis. 

Influence on Diplococcus, Spinal Exudate and Leukocytosis. — 
Soon after the injection of the serum was made, the diplococci be- 
came greatly reduced in number and wholly intracellular; they tended 
to disappear all together, to present changes in appearance, as swell- 
ing and fragmentation, to stain diffusely and indistinctly, and to 
lose mobility in cultures. In those with turbid and purulent exudates 
a rapid clearing occurred in some. Together with the clearing of the 
spinal fluid and the loss of pus cells is associated the return of the 
circulating leukocytes to the normal. 

Counts made before and after the injections often demonstrated 
a critical fall in the number of leukoc^rtes in the blood-stream. Un- 
favorable indications were a continuation of the leukocytosis, the 
turbidity of the exudate, and the persistence of the diplococcus after 
the serum injections. 

In the Journal of the American Medical Association, vol. li., 
No. I , Dr. Charles Hunter Dunn gives an analysis of 40 consecutive 
cases of cerebrospinal meningitis treated by Flexner's serum. 

In all the diplococcus intracellularis was found in the cerebropinal 
fluid. Dr. Dunn's method was to make a lumbar puncture in every 
suspected case. If the cerebrospinal fluid was cloudy, the antiserum 
was used at once without waiting for a bacteriologic examination. 



394 NKRVOUS DISORDERS 

If the fluid was clear, no antiserum was given until subsequent exam- 
ination revealed the presence of the meningococcus. 

In cases in which other organisms, such as streptococcus or pneu- 
mococcus, were found in association with the meningococcus, the 
serum was not repeated, but in the cases showing multiple infection 
in which it was used no apparent harm resulted. 

In the cases in which a rapid and marked improvement occurred 
after the first injection, accompanied by a permanent fall of tem- 
perature to the normal, no further injection was given. In cases in 
which this did not occur, the injections were repeated daily until the 
nervous and subjective symptoms were completely relieved and the 
temperature had reached the normal or until four doses had been 
given. In resistent or relapsing cases further doses were given. Dr. 
Dunn's routine dose was 30 cc, the largest dose given was 45 cc. 

In instances where the amount of fluid obtained was small, and in 
all instances where too great an increase of intradural pressure was 
feared, smaller amounts were injected, the minimum being 10 cc. 

Of the patients treated by Dr. Dunn, nine died and thirty-one 
recovered. A mortality of 22.5 percent. This, it will be seen, corre- 
sponds with the mortality of Dr. Flexner's cases. Among the patients 
who recovered one was deaf, and another blind and deaf. The recov- 
ery was complete in 72.5 cases. 

^Effects of the Serum. — According to Dr. Dunn, the three principle 
effects of the serum were, first, to produce a fall of the temperature; 
second, to produce a rapid improvement in the patient's general con- 
dition, accompanied by a more or less marked relief of certain symp- 
toms, and third, to cut short the disease. 

The effects on the symptoms and general condition is the most 
striking phenomenon observed in the use of the serum. In some 
there occurred a permanent return to consciousness, a disappearance 
of mental dulness and delirium, of headache, hyperesthesia, tender- 
ness of the neck, and vomiting. These svmptoms, according to 
Dr. Dunn, were relieved in twenty-four hours after the first injec- 
tion, the patient changing in a remarkable way from a serious con- 
dition of coma to a favorable condition of normal mental activity. 

In other cases the improvement occurred more slowly, and in 
others, the late chronic cases, no effects were noticed. The rigidity 
of the neck and Kernig's sign were the most persistent, so that at 
times patients remained normal ir; every way, playing with other 
children in the wards while these signs persisted. 

Effects on the Cerebrospinal Fluid. — Successive examinations of 
the cerebrospinal fluid twenty-four hours after the injection showed 
a striking change in the character of the contents. The number of 
organisms seen is much smaller, the chief change being that the 
majority are intracellular. In the fourth fluid, after three doses, 
there are frequently no diplococci to be found. 



TUBERCULAR MENINGITIS 395 

Relapse occurred in seven of Dr. Dunn's cases, and each relapsing 
case responded to one dose of serum. 

Early Use of Serum Important. — The earlier the serum was used, 
the more marked its effects. In five the disease was suddenly aborted 
after one dose of serum, recovery being complete. In seventeen 
there was a rapid and permanent improvement. In twelve of these 
the serum was given in the first week, in three in the second week, 
and to one in the third week. In eight the serum had no marked 
effect. Of these, three were in the first week, the other five being 
late chronic cases. 

One patient in the late chronic stage began to improve after one 
dose of the serum and made a rapid convalescence. This would indi- 
cate that improvement is always possible in the presence of diplococci. 

Dr. F. S. Churchill ^ reports nine proved cases treated with the 
Flexner serum, with two deaths; one of these was of the fulminating 
type, the other entered the hospital moribund on the tenth day. 
Temperature, cerebrospinal fluid, and leukocyte effects were practi- 
cally the same as offered by Dr. Flexner and Dr. Dunn and need 
not be repeated. 

In closing, Dr. Churchill remarks: " As one watches the behavior 
of these patients after one, two, or three injections of this serum, he 
is impressed with the astonishing change which comes over them, 
the clearing mentality, the unsuffering expression of countenance, 
the evident comfort, even with a still retracted head and rigid muscles, 
and he is filled with an optimism as to the ultimate result which per- 
haps is not yet justified." 

Method of Use. — The method of procedure in using the serum is 
to withdraw by means of lumbar puncture at least 20 to 30 cc. of the 
cerebrospinal fluid. The barrel of the syringe, loaded with the anti- 
meningitis serum, is then screwed to the needle or canula which was 
used for the tapping and the serum forced into the spinal canal. 
One injection every twenty-four hours is advised until four have been 
given. If the case prove resistant or if there is a tendency to re- 
lapse, the treatment is to be repeated. 

TUBERCULAR MENINGITIS 

This disease offers us one of the most hopeless conditions we may 
be called upon to treat. I have never known a proved case to recover. 
Lumbar puncture (page 396) and withdrawal of the cerebrospinal 
fluid is useful here for diagnostic purposes and for relieving pressure 
symptoms, which are often most distressing. All that we can hope 
to do is to make the patient comfortable and supply nutrition. 
Children ill with this disease rarely die under two weeks or live longer 
than six weeks after the appearance of diagnostic signs. 

The details of management as to baths, packs, nutrition, and 
^Journal of American Medical Association, vol. li.. No. i. 



396 NE^RVOUS DISORDERS 

medication are exactly the same as those used for Acute Simple 
Meningitis, and will be found on page 391. 

LUMBAR PUNCTURE 
The site selected for lumbar puncture is a point parallel with 
the crests of the ilia and between the spinous processes of the third 
and fourth lumbar vertebrae. The child should rest on its side 
(see Fig. 43), sufficient pressure being exerted on the buttocks 
to make the spinous processes prominent. The Quincke needle 
(Fig. 44) should always be used in making the puncture. The 
stylet which fits the beveled edge of the point of the needle effect- 



r--^' " .^^^^py^^^^^^F -^- --^ 


: ^''"w^ - - -1 


^ 


^ . 


^'"'"■^., 


, 



Fig. 43. — Position for and Site of Lumbar Puncture. 

ually prevents its being plugged. The skin for several inches about 
the site of the puncture should be scrubbed with the tincture of 
green soap and alcohol. The physician's hands should be thoroughly 
disinfected. Considerable force may be necessary in order to enter 




Fig. 44.— Quincke's Needle. 

the canal. When there is a sudden giving way of the obstruction 
to the progress of the needle, we know that the canal has been 
entered. The puncture may be made in a line with the spinous 
processes or from the side, the needle being passed between the 
laminae. When the point of the needle has been introduced into 
the spinal canal, the stylet is withdrawn. The cerebrospinal fluid 
may escape with force in a stream as a result of the pressure or it 



CHRONIC INTERNAL HYDROCEPHALUS 397 

may exude drop by drop. A sterile tube should be in readiness 
in order to collect the fluid for examination. 

Lumbar puncture is often of value for diagnostic purposes, but 
its therapeutic value is practically 7iil. In meningitis the with- 
drawal of an ounce or two of the fluid will sometimes furnish tem- 
porary relief to the patient. The retraction of the head and the 
spasticity will generally be relieved for a time. I have repeatedly 
withdrawn the fluid in such cases, where there was a tense bulging of 
the fontanel, and after two or three hours have passed, the fontanel 
would still be found depressed; it would soon become prominent, 
however, and in eight or ten hours it often would be as tense as be- 
fore. The advantage of lumbar puncture, therefore, is largely of a 
diagnostic nature, only temporary relief being furnished the patient 
by the operation. The introduction of drugs into the canal for 
bactericidal purposes is valueless. 

CHRONIC INTERNAL HYDROCEPHALUS 

When hydrocephalus in infants is mentioned without definite 
qualifications, the internal is always the type referred to, the external 
being of extreme rarity. The discussion of this affection will neces- 
sarily be brief, for after the treatment of a considerable number 
of such cases in hospitals and institutions I am unable to recommend 
any treatment that has proved of the slightest value. 

A new operative measure is now being employed by Dr. A. S. 
Taylor, of New York, which consists in tapping one of the lateral 
ventricles and establishing drainage by means of strands of chro- 
micized catgut conducting the fluid to the subarachnoid space, 
where its absorption is hoped for. The operation is described by 
Dr. Taylor as follows: 

"An osteoplastic flap about two inches in diameter is turned 
down, with its hinge over the base of the mastoid and just above 
the level of the horizontal lateral sinus. In the lower part of the 
dura mater thus exposed, a semicircular flap, base downward and 
about one inch in diameter, is made. Frequently there are one 
or two distended veins beneath this dural flap, and they should not 
be damaged, for their walls are so friable that neither clamp nor 
ligature is of much use, and the bleeding is annoying. The brain 
immediately protrudes through this dural window. A slender 
aspirating needle is passed through the second temporo-sphenoidal 
convolution (which is the one protruding), inward and slightly 
upward until it enters the ventricle, when the clear fluid spurts 
out and is collected in a sterile tube for bacteriologic examination. 
Only a very small amount should be allowed to escape in this way. 

"The thickness of the brain tissue is measured b}^ observing the 
length of needle inserted when the fluid begins to escape. 

"The drain is now made of No. 2, forty-day, chromic catgut. 
Three loops (six strands), about an inch and three-quarters longer 



39^ NKRVOUS DISORDERS 

than the thickness of the brain, are bound together by a loose spiral 
of catgut, starting at one end and stopping so as to leave an inch 
and a quarter of the loops free. In other words, the drain consists 
of a shaft of six strands of catgut a half -inch longer than the brain 
thickness, and spreading from its base, three free loops of gut an 
inch and a quarter long. Around the shaft of the drain, but not 
covering its tip, are rolled three layers of car gile membrane. With 
a long, narrow-bladed thumb forceps the tip of the drain is seized 
and carried into the ventricle along the tract made by the aspirat- 
ing needle. The tip projects about one-half inch into the ventricle. 
The free loops of gut are slipped under the dura, between it and the 
brain surface, in different directions, but chiefly downward toward 
the great lymph spaces at the base of the brain. A sheet of cargile 
membrane is slipped between the dura and the catgut loops to pre- 
vent adhesions. Usually by this time sufficient ventricular fluid 
has escaped, so that the brain no longer protrudes through the dural 
window. The dura is sutured with catgut, the bone-flap is held 
in place by three or four chromic catgut sutures, the deeper soft 
tissues by catgut, and finally the skin with silk. A good-sized 
sterile dressing is applied with some pressure. 

**The site just above and behind the ear, with the puncture 
through the second temporo-sphenoidal convolution, was chosen 
because the body of the lateral ventricle is drained. Where anom- 
alies of the ventricles exist they most frequently involve one or the 
other of the horns. Afterward, moreover, the escaping fluid leaves 
the brain in close proximity to the great lymph spaces and venous 
sinuses at its base — a fact which favors its rapid absorption. The 
right side of the brain is chosen because, if any irritation of the 
motor areas occurs, the left side of the body is involved, and more 
particularly Broca's speech center is not disturbed, as it lies in the 
left hemisphere. The approach to the brain is easy; the brain 
need not be handled, and is but sHghtly injured in the insertion 
of the drain." 

ACUTE ANTERIOR POLIOMYELITIS— INFANTILE PARALYSIS 

In poliomyelitis we meet a disease by which we are singularly handi- 
capped. Prophylaxis amounts to nothing. The strong and the well 
are as frequently attacked as the delicate — perhaps more frequently. 
The recent severe epidemic (1907) through which we have passed has 
added nothing to our knowledge as to the management of this disease. 
We have had it demonstrated that many mild cases make a complete 
recovery. This took place in five out of thirty-eight cases which came 
under my observation. These did not recover, however, as a result of 
treatment. They recovered because the infection in them was mild. 

Treatment. — During the acute stage of the involvement of the 
cord our efforts count for little. We order that the child be kept quiet 
in bed, that a laxative be given, and that he receive light, easily 



DIPHTHERITIC PARALYSIS 399 

digested nourishment, and then, as far as the immediate conditions 
are concerned, we have done our Httle, but our aU. I have used 
the bromids and ergot and the iodids internally, and ice-bags and 
blisters over the spine at the site of the lesion, and am yet to be 
convinced that they are worthy the annoyance which they cause 
the patient or that the drugs are worth the indigestion they are 
apt to occasion. That the disease is due to an infection is probable, 
and in a given case our hope must be that the infection will be 
mild in character. The degree of involvement determines the re- 
sulting atrophy and loss of function. 

Later Treatment. — From ten days to two weeks after the acute 
stage has passed our efforts should be directed toward maintaining 
the nutrition of the affected muscle or groups of muscles. This is to 
be done by mechanical means, electricit}', and gymnastic exercises 
(page 569). 

The beneficial action of electricity consists largely in exercising 
the muscles no longer under voluntary control, and thus increasing 
their circulation and nutrition. The immediate object of the elec- 
tricity is to induce contraction of the muscles. Either the faradic 
or the galvanic current may be used. The faradic should first be 
tried, and if to this there is no response, the galvanic should be 
used. Sittings of from five to fifteen minutes may be desirable, 
depending somewhat upon the age of the child and the age and ex- 
tent of the lesion. The longer the duration of the disease, the 
longer should be the sittings. Once daily the parts should be 
massaged by one skilled in the work. When this is not available 
the mother or nurse may undertake with some advantage the sys- 
tematic manipulation of the affected muscles by kneading and 
rubbing. The further management is orthopedic, and consists in 
the prevention of deformities by the use of splints and braces or 
their correction by tenotomies and tendon transplantation. 

DIPHTHERITIC PARALYSIS 

Every child with diphtheria should be watched and treated 
as if diphtheritic paralysis were expected. It has occurred, to some 
extent, in 9 percent of my cases. The first sign of irregularity 
of the pulse calls for an enforced recumbent position and the use 
of strychnin. If marked irregularity of the heart action occurs 
early in an attack of diphtheria, myocarditis may be suspected, 
a condition which calls for as active measures of treatment as does 
the irregularity which may occur later, from the tenth day to the 
third week of convalescence, which usually means nerve involve- 
ment. The two conditions may occur in the same individual. 

The soft palate and the muscles of deglutition are most frequently 
involved. There may be paralysis of the pharynx and larynx. 
Next in frequency the muscles of the extremities are affected. It 
has been my experience that if the heart is to be attacked, signs 



400 NKRVOUS DISORDERS 

indicating it will be noticed early — soon after the paralysis of other 
parts is apparent — or it may be the earliest symptom, the first 
warning being the heart's irregularity, which maybe the only evidence 
of its involvement. 

Treatment. — If after ten days from the onset of throat para- 
lysis, or paralysis elsewhere, there is no evidence of cardiac 
involvement, it will be unusual for it to develop later, although 
this is by no means certain. Should it occur, absolute rest in the 
recumbent position is important. The patient should be con- 
stantly under the eye of an attendant. He must not be allowed 
to turn over in bed or to raise his head without assistance. A 
hypodermic syring-e loaded with y^-Q grain of strychnin and ^io- grain 
digitalin should be in constant readiness. Strychnin should be 
given these patients throughout the entire illness and well on into 
convalescence. In these cases we rarely have to deal with children 
under eighteen months of age, my youngest case of diphtheritic 
paralysis being fifteen months old, so that in the consideration of 
doses only children over one year of age will be referred to. For 
a child from one to two years old, -3^0- grain of strychnin may be 
given at three-hour intervals; from two to four years of age, from 
fio" ^^ TW'o grain at three-hour intervals. After the fourth year, 
TTo" to xJ-o grain may be given at three-hour intervals. When there 
is marked rapidity of the heart's action with irregularity and rest- 
lessness in those under three years of age, from one to two drops 
of tincture of strophanthus may be given with jV to yV grain of 
codein, and repeated at two-hour intervals. After this age one and 
one-half to three drops may be given with to to ^ grain of codein 
at two-hour intervals. The codein is to be discontinued as soon as 
the restlessness ceases. For those in whom there is simply paralysis 
of the muscles of deglutition or of the extremities, small doses of 
strychnin will be all the medication required, from -^^^ to -aio^ grain 
three times daily being sufficient. Troublesome features in the 
management of cases in which there is marked involvement of the 
palate, the pharynx, and the larynx, consist in the difficulty of 
feeding the patient and in the danger of aspirating food and mucus 
as a result of the paralysis. The tendency of diphtheritic paralysis 
is toward recovery, the time required being usually from four to 
eight weeks. 

Illustrative Cases. — A boy six years of age had a very mild at- 
tack of diphtheria, not of sufficient severity to necessitate his re- 
maining in bed. Two weeks after the attack, the time of his coming 
under my care, there was marked paralysis of the soft palate and 
pharynx which rendered swallowing most difficult. In spite of 
energetic treatment with strychnin hypodermatically, the paralysis 
soon involved the larynx, the masseters, and the muscles of all the 
extremities. Fortunately the heart or diaphragm was not in- 
volved. There was a constant flow of saliva which at times entered 



MULTIPLE XEURITUS 4OI 

the trachea unimpeded, causing severe paroxysms of coughing. In 
order to prevent this, the legs and trunk were elevated, the head 
being made the most dependent portion of the body. Swallowing 
was impossible and he was given by gavage every six hours as 
indicated completely peptonized milk, whisky, beaten egg, and 
strychnin. The boy made a complete recovery, but it required 
three months to accomplish it. In another patient, fifteen months 
of age, gavage was practised at six-hour intervals for five days, 
when solids could be swallowed. 

Gavage (page 140) is but little objected to by children after it has 
been used once or twice. It should be employed as soon as it is 
shown that enough nourishment cannot be taken by the natural 
means. If coughing results in attempts at swallowing, it means 
that the larynx is involved and that feeding by the usual means 
should not be attempted. Nutrition by means of the bowel may 
be brought into use, but it is not necessary unless there is cardiac 
paralysis, in which event the resistance of the patient might enter 
as a factor making gavage dangerous. Attempts at swallowing may 
be made from time to time. Semisolid substances, such as scraped 
beef and soft-boiled egg, will usually be better managed than fluids, 
because of the tendency of fluids to pass through the glottis. 

MULTIPLE NEURITIS 

Neuritis of this nature, aside from that following diphtheria, is 
not of as rare occurrence in children as is claimed by some authors. 

The disease may be due to various toxic agents through their 
specific action in producing an acute inflammation and degenera- 
tion of the peripheral nerves. Among the possible causes are 
malaria, the exanthemata, grippe, pneumonia, and typhoid fever. 
Lead, phosphorus, arsenic, and alcohol as possible causes are also 
to be kept in mind. Lead is a very unusual cause. Arsenic, phos- 
phorus, and alcohol, however, are used extensively as therapeutic 
agents during child-life, and should always be considered as 
possible etiologic factors. 

I recently saw two pronounced cases in two brothers following 
very severe scarlet fever. ]Many mild cases of neuritis in children, 
following exhaustive diseases with prolonged toxemia, are doubtless 
overlooked, the prolonged time required for the return of muscle power 
in the arms and legs after such diseases being attributed solely to 
muscle weakness. Sensory disturbances in children are not such 
prominent symptoms as the neurologist would have us believe, for 
the reason, possibly, that he usually sees only the more severe 
cases. The mild cases seldom come under his care. I have seen 
quite a number of the mild cases in which there were sensory dis- 
turbances and a diminished patellar reflex following lobar pneumonia 
with high temperature, and also after severe scarlet fever. 
26 



402 NERVOUS DISORDERS 

Treatment. — The management is largely palliative, there being 
a strong tendency to spontaneous recovery in from four to eight 
weeks from the onset. Exciting causes, such as the use of alcohol 
or some other drug, should, of course, be eliminated, when recovery 
usually follows. In those cases due to the toxemia of preceding 
disease, time and good care are usually all that will be required to 
effect a cure. If pain is present the best means of relief is the use 
of heat, the affected limb being bound in thick layers of cotton- 
wool. The salicylate of soda and iodid of potash are not to be given 
to young children. They produce no appreciable effect, except 
possibly a disturbance of digestion and a lessening of the appetite. 
Should the pain be sufficient to interfere with sleep, bromid of soda 
may be given in doses of from eight to twelve grains, for a child of 
from five to ten years of age, at bedtime and repeated but once. 
In using hypnotics in children, one drug should not be continued 
longer than three days. 

Codein is a satisfactory sedative for a child in case the bromid 
does not answer. For patients from five to ten years old, from one- 
tenth to one-sixth grain may be given at bedtime and repeated once 
after an interval of three hours. 

As a tonic I know of no better combination of drugs for a child 
with neuritis than the following, for a patient from five to ten years 
of age: 

I^. Strychninge sulphatis gr. i 

Extracti ferri pomati gr x 

Quininae bisulphatis 5j 

M. et ft. capsulae No. xxx. 

Sig. — One after each meal. 

If constipation is present or should result from the administration 
of iron, from one-third to one-half grain of extract of cascara may 
be added to each capsule. The capsules are given for ten days, 
followed by cod-liver oil for five days. The oil is given after meals. 
At the end of five days the tonic capsules are repeated, to be followed 
again by the oil. The patient should have the benefit of an outdoor 
life as early as possible. Electricity has not been necessary in my 
cases, neither has the use of orthopedic appliances been required. 
Massage may be used with advantage after the subsidence of the 
acute symptoms. It should be given by one skilled in the work. 

FACIAL PARALYSIS 
Paralysis of the facial nerve is not of infrequent occurrence in 
the young. It may result from forceps pressure at birth or from 
pressure exerted by the bony parts of the pelvic outlet. In later 
infancy or childhood it may be the result of trauma caused by 
operative manipulations; it may be of rheumatic origin; it may 
be due to cerebellar disease, or to exposure to cold. In one of 



CEREBRAL PALSIES 403 

my patients it was attributed to sitting by an open window in a 
railroad car on a cold day. The nerve in its outward passage through 
the fallopian canal may become diseased from the presence of a 
purulent otitis media. This is probably the most frequent cause 
of the paralysis. 

Treatment. — The management depends entirely upon the cause 
of the paralysis. If due to cerebral disease, but little is to be ex- 
pected from treatment. If due to an otitis media, surgical pro- 
cedures, such as establishing a free drainage to the cavity of the 
middle ear, to be followed by frequent hot irrigations, should be re- 
sorted to. If these are ineffective, the mastoid should be opened and 
the cavity drained posteriorly. Where the functional activity of the 
nerve is delayed, electricity may be brought into use, as is indicated 
below. Cases in which rheumatism is supposed to be a factor should 
be given the benefit of anti-rheumatic treatment by the use of the 
salicylates (page 489). If the case is due to cold or trauma there is 
a strong tendency toward recovery, without treatment. It is diffi- 
cult to judge of the value of such a therapeutic measure as elec- 
tricity; but the effect of exercising the paralyzed muscles and 
stimulating nerve conduction by its use must be of some service. 
If the electricity is used, five-minute daily sittings are all that are 
necessary, using the faradic current if it produces sufficient reaction. 
If not, the interrupted galvanic current should be employed. 

CEREBRAL PALSIES 

Three types of this affection are recognized by neurologists, 
the pre-natal, the birth, and the post-natal. 

Concerning the etiology of the pre-natal cases, considerable con- 
fusion and varying opinions exist. Degeneracy of the parents, alco- 
holism, syphilis, and trauma are supposed to be contributory causes. 
I have seen a large number of these undoubtedly pre-natal cases, 
and am unable to add anything from the etiologic standpoint. In 
several instances the patients have belonged to families of several 
children each, the other children being normal, with nothing worthy 
of note in the family history and with a normal, uneventful preg- 
nancy. 

Trauma at birth, whether due to the use of forceps or to com- 
pression of the head in a prolonged or abnormal delivery, may result 
in meningeal hemorrhages causing an immense number of cases 
of cerebral palsy. The obstetrician should always keep in mind 
that with him rests the possibility of making a hopeless invalid 
or an idiot of the child he is about to deliver. It is fully appre- 
ciated that under unusual conditions in obstetric practice certain 
risks of head injury must be taken for the sake of the immediate 
demands of the mother or the child, but the large number of cases 
of cerebral palsy and idiocy which I have seen have impressed 



404 NKRVOUS DISORDERS 

Upon me the necessity of treating the child's head during delivery 
with the utmost care. 

The pre-natal and birth palsies are often paraplegias or diplegias, 
and as such show a wide distribution of the lesions. In the post- 
natal or the acquired cases there is more apt to be a hemiplegia, the 
hemorrhages usually resulting either from blows, falls, convulsions, 
or infectious processes. A comparatively trifling injury is some- 
times sufficient to produce a hemorrhage. 

Illustrative Cases. — A five-year-old boy, a pronounced hemi- 
plegic with normal mentaHty, owes his present condition to a fall 
from his baby-carriage to the ground when nine months of age. 
The fall was followed by repeated convulsions and hemiplegia. 
He came under my care a few days after the fall. The clot was 
located, the skull trephined, the blood-clot removed, and the bleed- 
ing vessel ligated. The boy today walks well with a brace and 
will be able to discard it in a few years; the arm will probably 
never be of much service. 

Another child, fourteen months of age, was perfectly normal pre- 
vious to an acute attack of indigestion with high fever and con- 
vulsions. The seizures were repeated several times during the day. 
After the third convulsion, it was noticed that there was complete 
paralysis of the left side of the face and of the right arm and leg. 
The child died thirteen months afterward. His mental condition 
never cleared — he remained an idiot until death. 

Treatment. — The medical treatment of these cases of paralysis 
consists in maintaining a high degree of nutrition. Drugs are of no 
service. The management in general in the different types of cases 
varies, depending upon the intelligence of the patient, the location 
and extent of the paralysis, and the resulting deformity. Braces are 
necessary in many cases to prevent contractions and deformities 
or to aid in correcting those already present. In some of my cases 
of normal or fair mentality marked improvement has followed 
daily systematic manipulations and exercises (page 569) under the 
management of an expert in this line of work. 

A description of operative measures and a discussion of the 
cases in which they are applicable m.ay be found in all works on 
orthopedics. Systematic exercse, massage, and training in the 
use of the limbs should be the later management of all operative 
cases, in order that the patients may derive the full benefit from 
the operation. 

IDIOCY 

Generally speaking, there are two varieties of idiocy — the pre- 
natal and the acquired. There is a very close association between 
idiocy and cerebral palsy. Not all idiots suffer from paralysis, 
neither are all cases of cerebral palsy idiots; in the majority of 
the cases, however, when either is present, the other will be found 



IDIOCY 405 

associated in a greater or less degree — sometimes the mental, some- 
times the physical, infirmity predominating. 

The degree of mental impairment varies considerably, being de- 
pendent upon the location and severity of the brain lesion, and 
whether it is a sclerosis, porencephalus, atrophy, or is due to a lack 
of development. There are cases in which there is scarcely sufficient 
cerebration for the patient to recognize his parents, and others in 
whom it is difficult to determine whether they are within or without 
the border-land which we have come to regard as normal. The 
diagnosis in most cases can be made at a glance. In two of the 
types, both pre-natal, the Mongolian idiot and the cretin, some con- 
fusion may exist in differentiation. The latter will be discussed 
separately in another section. 

Treatment. — The management of idiocy is to be considered from 
two standpoints: First, as to the physical condition. Under this 
heading is included the correction of deformities and the management 
as to hygiene and nutrition. The latter, of course, should be the 
best obtainable in any given case. The other consideration rests en- 
tirely upon the mental aspect of the case and concerns not only the 
patient but the family and their immediate interests. It may be said 
that, without exception, the place for a mentally defective child is in 
an institution which is devoted to the care and teaching of such chil- 
dren. He should be placed where much will not be expected, where 
he will be associated with others of his kind, where his work and his 
play are adjusted and presided over by educated men and women 
who have made such conditions the study of their lives. The idiot 
has rights. He has a right to live out his unfortunate life in as 
pleasant a manner as possible, and this is better accomplished in 
an institution than in any individual home. Here, among other 
things, he is taught, according to his capacity to learn, useful occu- 
pations, and not a few thus taught become self-supporting. At 
rare intervals one is found who possesses remarkable mental traits 
along certain lines, traits which the average normal individual is in- 
capable of understanding. I have one such case under my care. 
Cases showing a moderate degree of infirmity often become skilled 
in handicraft. They execute mechanically with surprising accu- 
racy. There have been great geniuses of the past who in some 
respects were not considered mentally normal by their contempora- 
ries. 

It is impossible to form even a fair estimate as to how the men- 
tally defective child will develop, with age and suitable instruction 
from those who are best able to discover his possibilities. The 
placing of these children in public institutions is often strenuously 
objected to on sentimental grounds by the poorer elements of society 
because of their fears and prejudices against such institutions, and 
in consequence the child is kept at home, greatly to his detriment 



406 NERVOUS DISORDERS 

and to the decided injury of other children in the family. Time 
and again I have pleaded with the mothers and fathers of such 
children without avail. Few villages throughout the country do 
not have an idiot or an idiotic epileptic for school-boys to taunt 
and for school-girls to fear. Most pitiable objects are these human 
derelicts, with whom the State does not interfere because they are 
** harmless." The prejudices of parents are largely due to the spas- 
modic attacks of virtue of the so-called "yellow" press, which peri- 
odically writes up, often with illustrations, under glaring headlines, 
the abuses in this or that public institution, all of which is solely 
in the interest of their circulation. Sooner or later, if he lives, the 
idiot of poor parentage will become a public charge, and the better 
his condition at the time, the happier he will be. 

Parents of means and intelligence will usually place such a child in 
one of the many private institutions that are conducted for the care 
of defectives; but the objection will often be raised, even by these 
people, that in such children there is so little mentality that teach- 
ing is useless. This may be true, but if for no other reason, the 
child should be removed from the home because of his invariably 
pernicious influence on other members of the family. The vicious, 
the unclean, and those showing marked moral degeneracy should be 
placed in institutions as soon after the fourth year as possible. If 
they are to be a public charge, they should be removed from the 
home as soon as they arrive at the age limit which the rules of 
the institution require for admission. If the patient is tractable, 
he may remain at home until the sixth or seventh year, particu- 
larly if there are no other children in the family. In the event 
of younger children whose natural tendencies and powers of imita- 
tion are always strong, the defective child should be removed as 
early as possible. 

ERB^S PALSY— OBSTETRIC PARALYSIS 
This paralysis is due to an injury of the brachial plexus during 
labor. There is little or no power in the muscles supplied by that 
portion of the plexus which is the seat of the injury. The arm 
hangs limp by the side. The tendency of these cases, whether in- 
volving the upper or the lower arm, is toward recovery unless the 
nerve lesion is a very grave one. 

Treatment. — The atrophy and contractions which develop are de- 
termined largely by the extent of the injury and to a lesser degree 
by the treatment. During the first three weeks in lifting and hand- 
ling the infant the arm should be protected from other injuries such 
as may take place in bathing and the other manipulations necessary 
in the care of a baby. After this time, massage of the entire arm 
and shoulder with lanolin should be practised at least twice a day, 
from ten to fifteen minutes at a time. After two weeks, electricity 



ANGIONEUROTIC EDKMA 407 

may be used for a few minutes each day. If the child can bear it, 
the faradic current answers best. But in case there is no response to 
faradism, the galvanic current should be used. Under massage and 
electricity, the improvement in the arm is often most satisfactory. 
It is not well, however, to promise the parents that a normal arm 
will be the outcome. I have seen cases in which there was almost 
complete restoration of power after it had been entirely lost, while 
in others the arm was permanently disabled. The degree of im- 
provement is dependent upon several factors, the chief one of which — 
the extent of the nerve injury — is in every case uncertain. Opera- 
tive measures consisting of grafting and transplanting of the nerve 
have been advocated recently by many surgeons. I have had no 
experience along this line. It would seem to be worthy of trial 
when it is demonstrated that the case has made all the improvement 
that it would be likely to make with other treatment. 

HICCOUGH 

Hiccough is a spasm of the diaphragm, usually due to gastric 
irritation from the distention of the stomach or intestine with gas 
or overloading of the stomach with food. Under such conditions 
it is usually of little consequence, and may readily be relieved, if 
the attack is prolonged, by an enema of soap-water and a laxative 
dose of rhubarb and soda. When it occurs with any grave illness, 
it is a symptom of serious import. Hysterical girls will often have 
hiccough to quite an alarming degree. The attack usually follows a 
period of unusual excitement. In these patients, from twenty to 
thirty grains of bromid of soda repeated in from twenty to thirty 
minutes will usually control the spasm. 

ANGIONEUROTIC EDEMA 
Angioneurotic edema is sometimes referred to as "giant hives." 
When it occurs in young children, it is most apt to involve the tongue 
and lips. When involving the soft parts, the urticarial lesions 
often produce an immense amount of swelling. This is particularly 
apt to be the case when the tongue and lips are affected. I have 
seen the lips swollen to several times their normal thickness. In 
the case of a boy four years of age, the tongue and lower lip were 
tremendously swollen. Speaking was impossible and swallowing 
difficult. It was supposed that he had been given carbolic acid 
or some corrosive poison. These cases usually develop suddenly 
and are apt to occasion great alarm. In the case referred to, I 
was called thirty miles into the country to see the child in consulta- 
tion. Cases have been reported in which the swelling of the tongue 
was sufficient to produce suffocation, necessitating incision into the 
tongue to reduce the swelling. The cases I have seen have always 
been associated with gastro-enteric disturbances. The swelling 



4o8 NERVOUS DISORDERS 

usually disappears very rapidly, although not quite as rapidly as it 
develops. At the end of twenty-four hours but a slight enlargement 
ordinarily remains. 

The treatment of this form of urticaria is the same as that of 
urticaria in general. The intestinal canal should be kept purged 
with saline laxatives and the patient put on a barley and broth 
diet for two or three days to relieve the intestinal tract. 

For local purposes, where the mucous membrane alone is involved, 
a two percent solution of sodium biborate in water, applied on 
pieces of old linen, has given the best results. This may be con- 
tinued until the swelling becomes greatly reduced or entirely dis- 
appears. 



SYPHILIS 

PRIMARY CONGENITAL SYPHILIS 
Treatment. — The only means of treating congenital syphilis in 
infants is by the use of mercury, either locally, as by inunctions, 
by internal administration, or hypodermatically. The hypodermic 
use of the mercurial preparations, such as the albuminate or the 
salicylate, are, for obvious reasons, not to be advised in young 
children. The use of the needle would have the effect of sending 
the patient to others for treatment, particularl}^ if the case were 
seen in out-patient practice. The use of the mercurial ointment 
by inunction is a satisfactory method in hospitals and in children's 
institutions, where a nurse can make the necessary applications; 
in private, however, it is objectionable because of the inunction itself, 
which may cause comment, and because of the staining of the skin. 
In fact, this treatment cannot well be carried on without other 
members of the family becoming acquainted with the nature of the 
illness. Definite rules for the management, as regards kissing 
and the care of feeding utensils, should be given, so that the other 
members of the family may be protected and the real condition 
remain unknown. Among the poorer class and in out-patient work 
I have found the inunction method unsatisfactory, for the additional 
reason that its use is not continued sufficiently, and it is very apt 
to be indifferently done. It is often postponed and forgotten, 
and as the disease permits of no temporizing, it is for the interest 
of the patient that the most effective means possible for its con- 
trol be brought into use at the earliest possible moment, and that 
is by internal administration. 

If the inunction is employed, the mercurial ointment, U. S. P., 
should be used, ten grains being rubbed into the skin daily. The 
rubbing should be continued about ten minutes, as this time will 
be required for the ointment to be thoroughly rubbed in. The use 
of mercury internally gives the best results among all classes. It 
is my observation, after the treatment of several hundred of 
these cases, that the bichlorid of mercury in small, frequently re- 
peated doses is the best medication. It is given in tablet form. 
Its use will have to be continued for a long time, and, as people 
are fond of giving drugs, we cater to the weak side of human na- 
ture, and thus do the greatest good to our patient. 

Mercury — The Dosage and Method of Administration. — For all 
infants under one year of age the scheme of medication is the same, 

409 



4IO SYPHILIS 

and this one covers the great majority of our cases. Usually they are 
seen before the third month. I order the tablet triturate of bi- 
chlorid of mercury, -g-^o grain. The mother is instructed to give 
two tablets daily, morning and night, after feeding. She is told 
to give on alternate days an additional tablet, after feeding, until 
five are given daily or until the mercury produces loose green 
stools. It is comparatively rare that an infant of the tenderest 
age cannot take 4V grain daily without inconvenience. If green 
stools with a watery tendency result, the increase is temporarily 
withheld. It is very rare that the above amount will not ultimately 
be taken without inconvenience. Further, the dosage of from 
4V to -3V grain in twenty-four hours, in the great majority of the 
cases, is all that is necessary to control the disease. If an improve- 
ment does not take place after a week's administration, in the ab- 
sence of intestinal symptoms, the amount may be increased to -^ 
grain in twenty-four hours. 

If, after the administration four or five times daily of the bi- 
chlorid in the small doses of 2"io" grain has been continued for 
several days, improvement does not take place because of failure 
on the part of the child to absorb the drug, inunctions may be used 
in addition to the internal treatment. They have been needed, 
however, in but few of my cases. 

Convalescence. — In a typical case the first sign that the child is 
improving will be the fading of the rash. It disappears gradu- 
ally, leaving the characteristic staining of the skin, which also clears 
up in a few weeks. Coincident with the fading of the rash, the coryza 
becomes less pronounced and the hoarse voice becomes clearer. If 
there has been an enlargement of the liver and spleen, after a few 
weeks of treatment, they will be noticed to have diminished in size. 
The child gains in weight, and if the case progresses satisfactorily, 
soon looks Hke a normal baby. This is not always the happy out- 
come, however. Occasionally we have cases which apply for treat- 
ment with the vital powers greatly depressed or with so intense an 
infection that treatment is of no avail, and they die in a few weeks 
from marasmus. 

The enlargement of the epitrochlear glands is, in my experience, 
the last sign to disappear, and in many cases these glands, though 
reduced in size, always remain enlarged without any other persis- 
tent evidence of the disease. 

Later Treatment. — What should be the further management 
of such a so-called "cured " case? Are we justified in discharging 
the patient and allowing him to pass from under our observation? 
My experience proves the contrary, nor can I state that congenital 
syphilis is ever cured. I have seen many cases, however, that were 
apparently cured, and which showed no signs whatsoever of the 
disease. Against my advice, they have passed from under observ^a- 



TARDY HKRKDITARY SYPHILIS 4II 

tion for two, three, or four years, and then reappeared for treatment 
because of the presentation of some manifestation of a tertiary 
lesion — a so-called ''tardy hereditary syphilis." 

My instructions to the parents or guardians of my syphilitic 
patients apparently cured, are to bring them to me once in three 
months for examination. If they remove to such a distance that 
this is not possible, then I ask them to take the child at the speci- 
fied time to some other physician and explain to him the nature 
of the previous illness. For such patients as return, for the first 
two or three years, I often advise a course of bichlorid for one 
month out of every three. I do not feel that it is necessary for such 
a child to show positive specific signs in order to receive this inter- 
rupted treatment ; if he shows retarded growth or anemia or a his- 
tory is given of his lack of resistance to disease he should unquestion- 
ably have the advantage of the treatment. In such a case I find 
that the improvement is much more satisfactory when some prepa- 
ration of mercury is used to supplement whatever restorative treat- 
ment may be suggested. 

TARDY HEREDITARY SYPHILIS 

By tardy hereditary syphilis it is understood that, for some 
reason, the infection failed to manifest its presence with any appre- 
ciable severity until the period of childhood was reached. 

In its selection of anatomic sites for its development, and in 
the nature of the lesion, it closely resembles the tertiary form in 
the adult. The eyes, the bones, and the nervous system are par- 
ticularly apt to be involved. The development of the Hutchinson 
teeth and the involvement of the shafts of the long bones, resulting 
in a periostitis, are its most frequent manifestations, these together 
with general malnutrition, are almost always associated with the 
disease in childhood. 

Treatment. — As in the treatment of tertiary syphilis in the adult, 
so likewise in the treatment of the late hereditary form in children, 
the iodids play an important part. Much better results, however, are 
obtained with the so-called "mixed treatment." The iodids alone 
are not sufficient to give us our best results, and the results with 
mercury alone are not so prompt and satisfactory as when the two 
drugs are combined. For an average case of periostitis involving 
the anterior portion of the tibia in a child four years of age, from 
-^ to yV gi'^^in of bichlorid of mercury should be given daily, com- 
bined with sufficient iodid of potash to produce the characteristic 
coryza. This may necessitate the giving of from twelve to twenty 
grains daily, as children vary greatly in their susceptibility to the 
drug. The mercury and the iodid of potash should not be given 
in one mixture, as the combination is most disagreeable to the taste. 
It is far better to give the bichlorid in the form of tablet triturates. 



412 SYPHIUS 

The iodid of potash is best given in a saturated solution, one drop 
of which represents one grain of the drug. This is best taken when 
dropped into milk after meals. Beneficial results from the treat- 
ment will usually be apparent in a few days. If there is a periostitis, 
the pain will be the first symptom to disappear. 

The administration of the iodid of potash should always be 
interrupted, chiefly because of its possibilities of deranging the 
child's digestion. I usually give it for ten days, followed by a rest 
of five days, when it is again resumed. Proper nutrition in these 
cases is a most important factor in their management. If the 
iodid is given to the point of tolerance, its omission for a few days 
will not be noticed. The mercury is given for weeks continuously in 
doses of from -^-q to 2-V grain three times a day, graduated according 
to the age. Later, when the progress of the case shows that the 
disease is under control, the two drugs should be given alternately, 
for ten days each. How long this treatment should be continued 
must be determined by each individual case. Cases which are 
apparently cured should be instructed to report to the physician 
every three months. I frequently advise a course of treatment for 
three or four weeks, two or three times a year. A sufficient excuse 
for such action may be the condition of the child, who may show 
a tendency toward slow growth and improper nutrition. The pa- 
tient should be kept under observation for years. He should be 
seen at stated intervals until the adult period is reached, when the 
nature of the trouble should be explained to him. The disease from 
which the child is suffering should always be made plain to parents, 
or at least to one of them, in order that the patient may not be 
allowed to pass from under medical observation in ignorance of his 
true condition. 

TARDY MALNUTRITION OF SYPHILITIC ORIGIN 

The possible manifestations of syphilis in the young, as in the 
adult, are many. In children, not the least interesting and impor- 
tant are the cases in which late malnutrition is the only evidence 
of the syphilitic infection. The patients are usually thin, some- 
times sallow, sometimes pale, with little or no adipose tissue. They 
are almost always undersized, as regards height, always under- 
weight, the appetite is poor, and they have but little endurance 
and correspondingly little resistance. The cases seen by me were 
between three and ten years of age. When two such children are 
seen in a family, in which both parents are robust, it is a strohg 
indication that they are suffering from the results of a remote syphi- 
litic infection in one of the parents. The physical examination 
may prove nothing definitely. 

Cases of late malnutrition, non-syphilitic in character, due to 
poor hygiene and faulty feeding, may present symptoms identical 



TARDY MALNUTRITION OF SYPHILITIC ORIGIN 413 

with the above, so that while the two conditions cannot be differ- 
entiated by the clinical signs, there may be sufficient grounds for 
suspicion to warrant us in questioning the father, when the history of 
a primary sore with perhaps secondary lesions may be elicited. 
There may have been prolonged treatment with a subsidence of all 
the symptoms, and the patient may have been pronounced cured 
and told that it was safe to marry. Many times have I heard this 
story when the evidence of transmission was before me in the form 
of a typical case of congenital syphilis. 

Treatment. — Treatment of tardy malnutrition of syphilitic origin 
by the supportive and restorative methods used in the non- syphilitic 
malnutrition cases is without avail. (See Tardy Malnutrition, page 
164.) These patients require mercury either alone or combined 
with the iodids. To the usual methods of treatment with iron, 
cod-liver oil, baths, and massage, there will be but little response, 
but add bichlorid of mercury or the iodid of potash and the case 
improves, slowly to be sure, but the improvement is invariable. 
In the management of such a case the child should be given the 
advantage of an outdoor life with free ventilation of the sleeping- 
room at night. The food should be highly nutritious, containing 
a large amount of proteid. Eggs, meat, milk, and the high-proteid 
cereals, such as oatmeal, are the most valuable. The dried legumes, 
— peas, beans, and lentils, — given in the form of purees, are a valu- 
able addition to the diet. Salt baths at bedtime (page 31) during 
the entire year, followed by oil inunctions during the cooler months, 
are valuable in restoring the child to a vigorous condition. As 
these children are almost always anemic, it may be well to combine 
the bichlorid of mercury with nux vomica and quinin. For a child 
from five to ten years of age, the following prescription has been 
used with marked benefit : 

I^. Hydrargyri bichloridi gr. ss 

Tincturge nucis vomicae gtt. xc 

Extract! ferri pomati gr. x 

Quininae bisulphatis 5 j 

M. div. et ft. capsulae No. xxx. 

Sig. — One capsule after each meal. 

This is given for ten days, when the bichlorid of mercury in tablet 
form — -gV grain three times daily after meals — is given for ten days. 
During the ten days when the bichlorid is given alone, maltine and 
cod-liver oil may be given — one dessertspoonful three times a day 
after meals. In these cases, iodid of potash is not to be given early 
in the treatment, for the reason that the appetite is usually poor or 
indifferent, and the administration of the drug at this time might 
further decrease the desire for food. The iodid of iron may be used 
in doses of ten to fifteen drops, three times daily, should the physician 
desire to change the form in which the iron is administered. 



414 SYPHILIS 

Prolonged treatment will usually be required. These cases 
should be kept under close observation for at least two years, or 
until they arrive at adolescence, when they should be made ac- 
quainted with the nature of the disease. During the entire growing 
period the administration of mercury during one month out of every 
three, or possibly every six, depending upon the child's condition, 
will insure better growth and a more vigorous development both 
physically and mentally. 



DEFORMITIES 

INGUINAL HERNIA 

Inguinal hernia is of rare occurrence in girls but comparatively 
frequent in boys. Predisposing causes, other than the anatomic, 
are whooping-cough and colic. I have seen several cases due to 
each of these conditions. In a Hke manner, constipation or difficult 
micturition may be a cause. 

Reduction. — The reduction of an inguinal hernia in an infant 
may be difficult because of the distended abdomen and the abdom- 
inal pressure exerted by crying. It is best accompHshed while the 
child, with legs and buttocks considerably elevated, is held by 
an attendant. Gentle manipulation with the thumb, index and 
second finger, which grasp the lower portion of the tumor, and 
pressure toward the ring, are usually successful. If reduction is 
not readily effected, it is better to anesthetize the child, after which 
it can usually be done with comparative ease. 

Treatment. — The treatment of inguinal hernia in infants and 
young children is by mechanical means or by operation. In in- 
fants under one year of age operation is rarely required. The 
most satisfactory measure in my hands for treating inguinal hernia 
has been by the use of a hard-rubber, cross-body truss. The pad 
should be but slightly convex. A hard-rubber truss is readily 
cleaned, and the cross-body truss keeps its position in young infants 
better than does any other. If there is a double hernia, the hard- 
rubber truss or the Hood frame truss, made of hard rubber, may 
be used. Measurement for the truss is taken around the hips on 
a plane with the hernia. The child should wear the truss day and 
night. By placing the truss in hot water for a few seconds or warming 
it slightly before the fire, it can readily be bent so as to fit the patient 
comfortably. When the truss is removed for the purpose of cleansing, 
which should be done twice a day, a helper should be at hand to 
support the ring so that there shall be no descent of the hernia. 
One descent may mean that several weeks' care has been brought 
to naught. It is well to keep the skin under the truss well pow- 
dered when first applied, and the child is often made more com- 
fortable by placing absorbent cotton between the skin and the hard 
rubber. 

As the child grows, the truss will have to be changed frequently. 
Its use should be continued for at least one year after the last descent 
of the hernia. Operation is required when the hernia becomes 
strangulated, and it is always to be advised in older children if a 

415 



41 6 DKFORMITIKS 

cure is not effected after two years' treatment by truss. Many of my 
cases have entirely recovered in less than six months. The use of the 
truss, however, is continued as just mentioned with a view to protect- 
ing the parts and preventing a recurrence of the hernia under stress. 

UMBILICAL HERNIA 

Umbilical hernia may be either congenital or acquired. However, 
nearly all cases may be said to be congenital, since the hernia is 
due, either to a failure in the closure of the ventral laminse, or to a 
defective development of the parts at the umbilical opening, which 
give way under pressure, such as straining in whooping-cough or 
in colic. 

The hernia may vary in diameter from one-fourth inch to one 
inch and may protrude as much as an inch and one-half. Occa- 
sionally cases are seen in which there is an associated ventral 
hernia immediately above the umbilical. Ten percent of dispen- 
sary cases under six months of age have umbilical hernias, and it 




Fig. 45 —Umbilical Hernia Reduced and Adhksive Plaster Applied. 

is by no means rare among the better classes. It usually makes 
its appearance during the early months of life. 

Treatment. — The treatment is entirely mechanical and consists 
in reducing the hernia and applying sufficient pressure to prevent 
its recurrence. By far the most effective means is bringing together 
over the umbiHcus (Fig. 45) the two lateral folds of the skin, so 
that they meet in the median line. The two folds of skin thus 
placed form a splint. Over this is placed a strip of Z. O. adhesive 
plaster one or two inches wide, the length depending upon the size 
of the child. Usually a strip from four to six inches long is re- 
quired. I have found this method much more satisfactory than any 
other, as it is followed by a more rapid cure. 

The objection to the use of the covered button or any other 
form of pad is that unless it is very large, it is apt to make strong 



SPINA BIFIDA 417 

pressure upon the abdominal opening, and while it reduces the hernia, 
the pressure exerted upon the abdominal ring prevents its rapid closure. 
Not only may it thus act mechanically in preventing the closing in 
of the abdominal wall, but, through interference with the circulation, 
the nutrition of the muscles is interfered with and the weakness 
persists. Umbilical trusses and bandages have been used repeatedly 
and all have been hopeless failures, and for one reason chiefly — the 
difficulty of keeping them in position. Any intelHgent mother 
or nurse can be taught in a few minutes how to apply the plaster 
as above suggested. The child may be bathed with the plaster 
in position. Ordinarily, it is best to apply a fresh piece every fifth 
day. Irritation of the skin under the plaster sometimes occurs. 
If there is a tendency to excoriation or redness of the skin, the 
folds can be made at right angles to those previously made and the 
plaster again appHed at right angles to the folds. By so doing, the 
excoriated skin remains uncovered. If the hernia is not particularly 
large and if the case is seen during the first, second, or third month 
of life, a cure can be expected in from three to six months. The 
younger the child, the more rapid will be the cure. Repeatedly, 
when treatment was begun within the first six weeks, I have seen 
a large hernia completely cured in a few months. In not one of 
my cases has operation been necessary. 

VENTRAL HERNIA 

This form of hernia is of congenital origin and is only occasionally 
seen in infants. It may be associated with umbilical hernia or it 
may occur independently. It may be due to a failure of the recti 
to unite in the median line or it may be due to a weakness or an 
imperfect development of the fibers of either muscle. 

There is rarely any great protrusion of the abdominal contents, 
as in the other forms of hernia. Usually a ventral hernia manifests 
itself in a fullness or a distinctly localized elevation of the skin over 
the site of the absent or weakened muscle tissue in the abdominal 
walls. 

The application of a four-inch strip of Z. O. adhesive plaster 
one and one-half to two inches wide, placed flat on the skin over 
the hernia, is all that will be required. The support thus furnished 
will have to be continued for several months. Operation may 
sometimes be necessary, but it has not been required in my cases. 

SPINA BIFIDA 
The results of treatment of spina bifida, regardless of its type 
or the method employed, will scarcely warrant us in promising 
parents much in the way of improvement. In my hands the injec- 
tion of iodin has not been of any value. The pressure treatment is 
unsatisfactory. Surgery promises better results than does any 
27 



41 8 D^FORMlTms 

other treatment. Operative measures are fully described in works 
of surgery and the results are sometimes brilliant. Operations, 
however, are not without immediate danger, for in a great ma- 
jority of the cases portions of the cord are within the sac, the 
excision of which may result in permanent paralysis and deformity. 
It is the duty of the family physician to see that the tumor is care- 
fully protected and kept clean and the child properly nourished 
until such time as operation by excision or otherwise is thought 
advisable, which ordinarily is not until the child is one year of age. 

HARELIP 

The time for the operation for harelip depends, within certain 
limits, upon the condition of the child. Some surgeons prefer to 
operate very early and others when the child is several months 
old. Ordinarily the operation should not be performed before the 
patient is one month old or delayed after the fourth month, if the 
child's condition and the season of the year permit. Operations 
on young children should not take place during the hot months 
because of the lack of resistance on the part of a young infant to 
the shock of an operation, and because of the dangers of gastro- 
enteric complications, the latter being considerable. The matter 
of feeding need not hasten the operation if other factors in the case 
are unfavorable for it. The child with harelip may be successfully 
fed by gavage (page 140) for an indefinite period. 

HEMATOMA OF THE STERNOCLEIDOMASTOID 

The tumor which is formed in a portion of this muscle is 
caused by an injury during birth, and consists of a rupture of the 
muscle-fibers and of the blood-vessels. The tumor may be small, 
not larger than a filbert, or it may involve a considerable part of 
the muscle structure. When much of the muscle is included in the 
tumor, the head of the patient is held in a constrained position with 
the face directed toward the affected side. The tendency of these 
cases is to recover without treatment, but it has seemed to me, from 
an observation of several cases where it was employed, that the 
absorption of the tumor was hastened by massage, which should be 
practised for fifteen minutes three times a day. A moderate stretch- 
ing of the muscle by forcible rotation of the head toward the 
unaffected side and upward appeared to be of benefit in a few cases, 
the movements being practised at the same time as the massage. 

CLEFT PALATE 

Cleft palate may involve either the hard or soft palate, or both. 

The time for operation, and the nutrition until such time arrives, 

are all that concern us. Operation should not take place during the 

first year, and is better performed between the first and the second 



CLEFT PALATE 419 

years, but not later than the second, as the result is much more satis- 
factory than if left to a later age. The feeding of the patient is 
usually considerably interfered with. The child is rarely able to 
take the bottle, and the various devices for the formation of an 
artificial hard palate are usually failures. Sucking on the bottle or 
nipple is, of course, out of the question. A spoon or a large medi- 
cine-dropper may be employed in feeding, but their use is tiresome 
both for the attendant and the child. By far the best method of 
feeding in these cases is by gavage (page 140). The nutrition of the 
child may thus be maintained for months, and with results quite as 
good as by natural methods. I have a child ten months of age 
under my care at the present time who has always been fed by 
gavage at intervals suitable for his age, and his development has 
been perfect, 



DISEASES OF THE SKIN 

ECZEMA 

When one considers the sensitive nature of the skin and its 
constant exposure to all sorts of irritating influences it cannot be 
surprising that skin affections are more frequently seen in infants 
than are any other ailments; and when one recognizes in the skin 
an organ of absorption, secretion, and excretion, the importance 
of a careful study of its lesions will be self-evident. Inasmuch, 
therefore, as what is known as eczema is characterized both by 
acute and chronic inflammations of the skin, the fact that in its 
different forms it comprises a large percentage of the skin diseases 
of young children is readily understood. From an etiologic stand- 
point, eczema in children may be divided primarily into two classes: 
those forms due to causes operating from within — systemic condi- 
tions; and those due to causes operating from without — local irri- 
tations of whatever nature. 

Manifestations. — The manifestations of eczema are subject to 
most sudden changes, an apparently normal skin today developing a 
weeping eczema tomorrow, while a few days later the skin may again 
be clear. It is difficult and unnecessary in children to attempt 
any such differentiation of the various types of eczema as is laid 
down in works on dermatology ; and indeed such a differentiation 
is difficult, for the reason that in children eczema is not confined 
to the special adult types, but rather to various combinations of 
lesions, — every variety of papule, vesicle, pustule, and fissure being 
often seen in one patient on a surface area of only a few square 
inches. Infections of the involved areas resulting in pustules and 
furuncles are more common in children than in adults, because 
of the ready inoculation and transmission of bacteria through 
manipulation and scratching, and because of the diminished re- 
sistance offered by the child to pyogenic organisms. 

Cases Originating from Within. — Such cases are by far the more 
frequent and the more troublesome. The most susceptible age is 
from one to twelve months. While cases which have developed 
during the earlier months may be carried over into the second or 
into the third year, it is comparatively rare for this to happen, 
as it is also rare for cases to develop after the nursing age. At 
this early period the inflammatory process may be limited to a 
round weeping spot on each cheek, or it may involve all the flexor 
surfaces, or it may cover larger portions of the skin surface and 
show all the clinical phases of the disease. The physical condition 

420 



ECZEMA 42 1 

of the child exerts no influence upon the development or persistence 
of the eczema. 

Some of my healthiest nursing babies — those who made most 
satisfactory progress and were well in every other respect — were 
sufferers from eczema until the nursing period was over or until 
nursing was discontinued and other food given. In fact, the ma- 
jority of my cases, both breast-fed and bottle-fed, have been in 
children whose condition was otherwise satisfactory. There were 
others, to be sure, who suffered from malnutrition or who were 
difficult feeding cases. In some of these the eczema was, doubtless, 
a factor in causing the malnutrition ; for on account of the excessive 
itching, restlessness, and sleeplessness, the child's strength had 
become so markedly reduced that malnutrition was just as liable 
to be a result as a cause of the eczema. Athreptic and malnutrition 
children are very apt to be free from eczema of an acute inflamma- 
tory type; the cases we are considering, however, are due to intes- 
tinal indigestion and faulty metabolism of such a nature as not to 
interfere with nutrition. We know from clinical experience that 
no one cause is operative in all cases, and we know also that our 
management, to be effective, must be directed toward the in- 
testinal tract and the liver. 

Several of my patients who have been sufferers from eczema 
in babyhood have in later life developed some recurrent illness, 
such as bronchitis, asthma, or recurrent vomiting. Not a few of 
these persistent eczemas in infants are associated with gout and 
rheumatism. In out-patient work a great many cases of acute 
eczema are seen, and they are not infrequent in office pediatric work. 
Not all cases are relieved by treatment, but usually some way may 
be found to relieve most of them. In a few, regardless of treatment, 
the eczema persists in a less aggravated form, until the child is 
weaned or until milk-feeding can in a measure be discontinued. 

Treatment. — In the breast-fed, a proper regulation of the nurs- 
ing as regards time and quantity may be sufficient. The relief of 
the constipation of the mother is all that is required in some eczem- 
atous, breast-fed infants. The eczema which is due to high fat or 
high proteid, or both, in the breast-fed may be relieved by regulating 
the diet of the mother (page 74) and by insisting upon reasonable 
exercise. If the child is thriving, making a satisfactory gain in 
weight, the nursing should never be discontinued because of the ec- 
zema. If the mother or wet-nurse has been indulging in too rich 
food, drinking beer, tea, or coffee in excess, they should be discon- 
tinued and a very plain diet substituted. Two grains of bicarbonate 
of soda given in two drams of water before each nursing is often of 
service. Of late, in those cases of eczema in which the urine has 
shown marked acidity I have given with apparent benefit two grains 
of citrate of potash, three times daily. 



422 DISK ASKS OI^ THK SKIN 

In the bottle-fed, the correction of errors in feeding is easier, 
and, as a whole, such cases are more satisfactory to treat than are 
the breast-fed cases. The eczema may respond to the treatment 
of constipation if it exists. It is impossible in a given case to tell 
whether the feeding as a whole is a cause of the trouble, or some 
one of the nutritional elements is at fault. My usual way in the 
bottle-fed is to give a food upon which the child may be ex- 
pected to thrive. If the eczema is pronounced, the sugar, for a 
week, is reduced perhaps to 4 percent. When this produces no 
effect, the 6 or 7 percent of sugar is resumed and the fat or pro- 
teid reduced. Working in this way, by a process of exclusion, 
I have discovered which element in the food was apparently at 
fault and the eczema has responded to its correction. The food 
should never be so manipulated that the infant will not thrive. 

Illustrative Cases. — One of my patients, a baby otherwise 
normal, had the most pronounced general eczema that I have ever 
seen, the entire skin surface being involved. For seven months — 
until he was past one year of age — I was unable to give this pa- 
tient more than i percent of fat. An increase to 1.5 percent of 
fat would be followed in one-half hour by an inflammation and 
redness of the skin. In another case almost as severe — one which 
I saw at the ninth month — I was unable to give cow's milk in any 
form. The condition was so aggravated that I discontinued en- 
tirely the fresh cow's milk and put the child on condensed milk, 
when the skin cleared promptly without any other treatment what- 
ever. About six weeks later fresh cow's milk was again tried in 
small quantities, with a prompt return of the eczema. At different 
intervals the cow's milk was given for one or two feedings daily, 
but we were always obliged to discontinue it because of the signs 
of the old trouble which immediately appeared after two or three 
cow's-milk feedings had been given. In a girl patient, four years 
old, one tablespoonful of beef juice or scraped beef will produce an 
acute eczema of the face and limbs, most intense in character, 
which requires several days to correct. The child's father has 
suffered severely with rheumatism for years, and in the mother and 
her ancestors gout in marked degree has been present for generations. 
This patient is further interesting, in that she is a cane-sugar sus- 
ceptible and formerly had attacks of cyclic vomiting every three 
to four weeks. Cane-sugar is never given even in the smallest quan- 
tity. Through the removal of red meat and cane-sugar the cyclic 
vomiting and the eczema have ceased. 

In these obstinate cases, as the urine is usually very acid and 
a deposit of urates will be found on the napkin, I invariably give 
bicarbonate of soda, one grain to one ounce of food, or two grains 
of citrate of potash three or four times daily. 

Local Treatment. — The local treatment in the cases of internal 



EJCZEMA 423 

origin is very unsatisfactory, and all that can be accomplished is to 
relieve the itching and make the child more comfortable. It may 
safely be said that in the treatment of eczema in infants more harm 
than good usually results from local measures. As a rule, too strong 
lotions and ointments are used, which, while they may not increase 
the irritation, produce enough to retard recovery. 

When the face is involved, showing a bright red or weeping 
surface, the application of bassorin paste usually gives relief. The 
paste dries on the parts and forms a firm protective dressing. The 
oil of cade — one-half dram to one dram, to one ounce of collodion — 
may be used. If there is a very acute infection, fifteen minims 
of the oil of cade to an ounce of either bassorin paste or collodion is 
the proper proportion. The face should not be washed nor the appli- 
cations removed. As it peels off, it should be freshly applied. The 
bassorin paste- will not bear the addition of liquids in any consider- 
able amount, but the oxid of zinc may be combined with it, as may 
also ichthyol and tar in small amounts. Ointments applied to 
the face, unprotected, are soon rubbed off and soil the clothing. 
The mask (Fig. 46) is used in out-patient and hospital cases. In 
private practice it is often objected to, but is absolutely necessary 
for the relief of not a few patients. When an ointment can be applied 
under a mask, or when it is to be used on other parts of the body 
where it may be bound upon the parts, the preparations of tar 
afford greater relief than any other application. An ointment com- 
posed of the unguentum picis, U. S. P., one part, with unguentum 
aquae rosae, from four to six parts — the strength used depending 
upon the irritability of the skin — may be applied at least morning 
and evening. It should be thickly spread upon old linen and bound 
firmly but gently to the parts. If the existing irritation is at all 
increased by the application, it should be weakened by a reduction 
in the amount of tar used. In spite of the eczema, these infants 
must be bathed. The bran or soda bath (page 31) may be used, 
care being taken to avoid too much friction of the skin. One of the 
most troublesome features in the treatment of eczema in 3^oung 
children, regardless of the location of the disease, is the certaintv of 
the patient scratching the involved parts, particularly at night. 
This obviously tends to keep up the trouble indefinitely. The 
straight- jacket (page 429) will effectually prevent the scratching. 

Eczema Due to Irritation from Without. — Eczema due to irri- 
tation from without is not unusual with sensitive skins. It may be 
caused by strong soaps, by vigorous rubbing, by irritating clothing, 
such as woolens, etc., or it may result from counter-irritation applied 
because of some respiratory disorder. Obviously, the management 
of these cases depends upon the removal of the source of irritation. 
In some of my cases where woolens cannot be worn I advise that 
^ Manufactured by Lehn and Fink, New York. 



424 DISEASES OF TH^ SKIN 

the linen mesh be substituted; in others that the garment which 
comes in contact with the skin be lined with thin soft linen. 

Eczema Intertrigo. — Eczema intertrigo is a result of maceration 
of the skin, where two skin surfaces are in constant apposition. 
It is most frequently seen in the skin-folds of the neck, the groin, 
under the arms, and on the flexor surfaces at the elbow-joint. At 
first there is usually a simple erythema, which if neglected 
develops into a characteristic eczema. The treatment consists 
in separating the opposed surfaces by pledgets of cotton freely 
dusted with equal parts of powdered starch and oxid of zinc. The 
cotton should be removed as soon as it becomes moist and fresh ap- 
plications made. Linen or gauze may be used in the same way. 
Usually this treatment promptly relieves the condition. 

A similar maceration of the skin may occur when the genitals 
and the skin over the inner portion of the thighs, the buttocks, 
and the lower abdomen are allowed to remain wet with decom- 
posing urine. With very few exceptions these cases are due to 
neglect. Athreptic and malnutrition infants furnish many of the 
cases. In a few infants well cared for intertrigo may develop. 
In these it may be explained by a very acid urine, or it may be 
one of the manifestations of seborrheic eczema (page 426). 

The treatment, with the exception of the seborrheic type (page 
426), consists in neutralizing the urine by the use of bicarbonate of 
soda — two grains three times daily — by protecting the skin surfaces, 
and, by attention to the napkin, preventing irritation from the dis- 
charges. Dusting- powders are of very little use here. The method 
which has been most satisfactory, and which I have followed 
with success for years even in the most unpromising subjects, is 
as follows: The mother or nurse is instructed to keep close watch 
of the napkin and change it as soon as it is soiled and not to reapply 
it until it has been washed. She is further instructed to prepare 
pieces of gauze or old linen of such shape and size as to cover the 
denuded surfaces. On these slips of linen she is directed to spread 
zinc ointment most plentifully. The dressing is then applied to the 
parts and is to be changed several times daily. Over this dressing 
the napkin is placed. The urine, which is chiefly at fault, is pre- 
vented by the ointment dressings from coming in contact with the 
skin, the treatment being solely protective. At the same time 
a quantity of absorbent cotton is placed next to the genitals so as 
to absorb the urine as it is passed and thus prevent its general dis- 
tribution over the parts. If the ointment is simply spread over 
the skin and the napkin applied, it will soon be absorbed by the 
napkin and be of no service. When the case is well advanced 
toward recovery, scrupulous cleanliness and a dusting-powder com- 
posed of equal parts of powdered starch and oxid of zinc will usually 
be all that is required. 



ECZEMA 425 

Chronic Eczema in Older Children. — A form of chronic eczema 
of comparatively frequent occurrence in out-patient cases remains 
to be described. Some writers refer to it as a "neurotic eczema " 
and others as a "reflex eczema." The predominating lesions are 
papules. The first local manifestations are papules, and they 
remain papules unless other changes are produced by scratching. 
Oftentimes the papule is tipped with a black speck which repre- 
sents dried blood and dirt — a result of scratching. A large portion 
of the skin surface may be covered by the eruption or it may be 
localized on the arms or thighs. Itching is a troublesome feature 
of these cases; in some it is almost unbearable, and the patient 
is often presented with the skin torn and bleeding. The disease is 
without doubt due to some low form of intestinal toxemia. Often 
the patient suffers from constipation; he may have a large, dis- 
tended abdomen and not infrequently quite offensive stools. 

Treatment. — The treatment consists largely of internal measures. 
The best initial internal medication for this condition is calomel ot 
rhubarb and soda, not sufficient to produce purging, although at the 
outset a purge may be of advantage. For a child from four to six 
years of age, from two to four grains of rhubarb with six grains of bicar- 
bonate of soda should be given twice daily between meals, for two, 
three, or more weeks; sufficient should be given to produce one 
or, better, two soft movements daily. The rhubarb and soda may 
be given in two drams of a solution of equal parts of aromatic syrup of 
rhubarb and water. Every fourth night at bedtime one-fourth grain 
of calomel is given. The diet suitable for the child's age (pp. 134- 
138) may be given. It generally means a radical change in the 
feeding methods, as the records usually show that these children have 
been very badly fed. Nothing is to be given between meals. The 
best local treatment is an ointment of salicylic acid or tar, either 
separately or combined. If there is an acute dermatitis as a result 
of scratching, only a weak strength of salicylic acid should be used, 
or it may be wise to omit it entirely until the dermatitis has subsided, 
using instead the plain zinc ointment, U. S. P., with the addition of 
menthol, as follows: 

I^. Mentholi gr. x 

Unguenti zinci oxidi § j 

After the acute dermatitis has subsided the following prescription 
answers well: 

I^. Acidi salicyjici • • gr- x 

Unguenti picis U. S. P oss 

Unguenti aquse rosae q. s. ad oij 

The ointment should be used twice daily, bound to the parts 
so as completely to cover the surfaces, thereby getting the full 



426 DISKASES OF THE SKIN 

benefit of the treatment and at the same time protecting the skin 
from further irritation by scratching. The cases are usually obsti- 
nate and treatment will have to be continued from three to six weeks. 
In those children who have been suffering from this form of eczema 
for a long time and who show extensive lesions, two or three months 
may be required to complete a cure. 

Seborrheic Eczema. — This form of eczema is due to an excessive 
secretion of the sebaceous glands which is dependent upon a func- 
tional derangement, probably inflammatory in character. It is 
believed by some dermatologists that the disease is dependent upon 
a specific infection. 

Seborrhea Capitis (Milk Crust). — The form in which it is most 
frequently seen in children develops on the head in the form of 
thick, dirty, yellow crusts, commonly known as **milk crust." In 
mild cases the crusts may be isolated or there may be one large 
patch with several surrounding smaller areas. In some cases the 
exudation is thick and uniform and covers the vertex of the head 
like a mask. The exudation consists of sebum, dirt, and desqua- 
mated epithelium. 

Treatment. — The first step in the treatment is to remove 
the crusts. The hair should be cut very short. If only a few areas 
are involved, anointing the parts with vaselin several times daily 
will soften them so that they may be removed. If the crust is thick 
and extensive it is best to soften it with sterilized olive oil, which 
is apphed on gauze or old linen. The material used, saturated with 
the oil, is held in place by a cap made of cheese-cloth. If the dressing 
is applied at bedtime the crusts may often be removed the following 
morning. In cases in which the exudation has existed for a long 
time and is very hard, it may require two or three days, with frequent 
fresh applications of the oil, to soften it sufficiently for removal 
without injury to the skin. When thoroughly softened it should 
be washed off with castile soap and warm water. After the crusts 
are removed, a reddish, slightly inflamed skin will usually be found 
underneath. To this is applied an ointment of resorcin and vaselin, 
twenty grains to the ounce. The ointment is spread on linen or lint 
and apphed to the parts, the gauze cap being worn to hold it in 
position. In many cases this treatment, used only at night, will be 
sufficient ; only the most aggravated cases need wear the cap during 
the day. A few applications of the ointment to the parts during the 
day will usually be all that is needed. A few days' treatment will 
often relieve the worst cases of seborrhea capitis, after the scalp 
has been freed from crusts. I have yet to see a case which did 
not respond when this treatment was properly carried out. It is 
to be remembered, however, that in these cases there is a tendency 
for the exudation to return. Mothers and nurses are instructed 
to keep the ointment in the nursery for use upon the first appear- 



ECZEMA 427 

ance of the exudation. In children, seborrheic eczema, according to 
my observation, is comparatively unusual in other portions of the 
body. Associated with the seborrhea of the scalp, the forehead 
and face may be involved. In these situations also resorcin is 
useful, but must be used in much weaker strength — from 0.5 to i 
percent. 

Seborrhea Intertrigo. — At rare intervals cases of intertrigo are 
encountered upon which no impression whatever is made by the 
methods of treatment suggested on page 424. Several years ago 
Dr. George T. Elliot, of New York, called my attention to the fact 
that these cases were of seborrheic origin, and that a change from 
the ordinary treatment to that ordinarily used for seborrheic ec- 
zema would prove his contention. In the cases in question, and 
in those that I have seen since, the point made by him has been 
confirmed by the treatment. Cases of seborrhea intertrigo are 
generally associated with seborrhea elsewhere, usually of the head, 
and show erythema, a tendency to dryness of the skin, and des- 
quamation. 

The treatment in this form of intertrigo consists in cleanliness 
and diet, as mentioned under Intertrigo, page 424. In addition to the 
usual means, from 0.5 to i percent of resorcin should be added to 
the ungt. zinci oxidi which is used as a dressing. Seborrheic eczema 
is not as difiicult of management as the other forms of eczema in 
children, but there is a great tendency for it to return, particularly 
in cases of low vitalitv. 



Fig. 46. — The Hertv JNIask in Position. 

The Mask. — In facial eczema the itching is often most intense. 
In order to effect a cure, scratching and rubbing the parts on any 



428 



DISEASES OF THE SKIN 



object with which the child may come in contact must be prevented. 
The Herty mask^ (Fig. 46) answers this purpose admirably. The 
ointment or lotion is placed on clean linen, which rests on the involved 
parts. Over this is placed the mask. In Fig. 47 is represented a 




Gather 

Fig. 47. — Pattern for the Herty Mask. 



pattern of the mask. Opening A is sufficiently large to furnish 
space for the eyes, nose, and mouth. An elastic band, which will 
be seen to pass over the upper lip, draws the sides of the opening 
together, insuring protection to the cheeks, usually the parts chiefly 




Thomas' Modified Straight-jacket. 



involved. B and C pass over the top of the head and are sewed to 
D and E, which pass over the ears to the back of the head, where 
they are united. The masks are best made of muslin or thin old 
linen and are to be renewed daily. 

iMade by Miss Herty, 420 West ii6th St., New York City. 



urticaria; hives; nettle-rash 



429 



The Straight- jacket. — One of the difficult features of treating 
children with eczema is the tendency for the child to scratch the 
involved parts. This not only keeps up the trouble indefinitely, 
but the nails are often the carriers of infection. I have seen not 
only severe dermatitis, but furunculosis and celluHtis develop in this 
way. One of the best means of preventing night scratching during 
the sleeping hours is in the use of the Thomas modified straight- 
jacket (Figs. 48 and 49). The jacket is made of muslin and must 




Fig. 49. — Thomas' Modified Straight-jacket in Position. 

be fitted to the patient. The child is shpped into the jacket feet 
first. The opening A encircles the thorax directly under the arms. 
The opening B is closed about the neck with the attached tapes. 
The cord which is used to close the end of the sleeves may be tied 
to the sides of the crib or pinned to the bedding. Children readily 
accustom themselves to the position of lying on the back, which its 
use necessitates. It is no kindness to allow a child to further irritate 
the already badly involved surfaces. 



URTICARIA; HIVES? NETTLE-RASH 
Urticaria is characterized by the sudden appearance and dis- 
appearance on the skin surface of wheals of vasomotor origin. The 
wheals, which are associated with intense itching and burning, are 
of different varieties and subside without desquamation. They 
vary considerably in size and shape, which fact has given rise to 
a differentiation into types for purposes of diagnosis. For our 



430 DISEASES OI^ THE SKIN 

purpose a division has to be made from the etiologic standpoint 
only. 

Urticaria may be due to agencies operating either from without or 
from within. An agency operating from without may be an irritant 
of almost any nature — the bites of insects, clothing which may 
irritate the skin, or clothing which is too tight. Contact with 
different plants may also produce the wheals. Such causes as these, 
however, are factors in but comparatively few cases. The manage- 
ment, obviously, is the removal of the source of irritation and the 
application of a simple ointment, such as one composed of ten 
grains of menthol to one ounce of cold-cream, or the parts, if not 
too extensive, may be bathed with a i percent carbolic solution. 

Irritation arising from internal sources is the cause of the condition 
in at least 95 percent of the cases. The use of certain drugs may 
furnish sufficient irritation to cause the outbreak. I have in not a 
few instances seen hives due to quinin, arsenic, or antipyrin. The 
administration of diphtheritic antitoxin produces urticaria in from 
15 to 20 percent of the cases. Certain articles of food, such as 
strawberries, tomatoes, oatmeal, and buckwheat, invariably cause 
urticaria in some children. Digestive disturbances of any nature, 
whether acute or chronic in character, may cause urticaria. In 
an attack, therefore, where no external cause can be discovered, 
and where drug idiosyncrasies can be eliminated, it is fair to assume 
that the source is the intestinal canal. A safe procedure is to give 
a full dose of castor oil — two to four teaspoonfuls — or one grain 
of calomel in divided doses, followed the next morning by the 
citrate or the milk of magnesia. At the same time, the diet, re- 
gardless of the age, should be reduced to broths and gruels, to 
which toast or dried bread may be added if the patient has been 
accustomed to it. Milk should not be given during the acute stage. 
A laxative, a reduced diet, and the application of the menthol oint- 
ment already referred to will usually be all that is required. In those 
that persist in spite of these measures, which include the antitoxin 
cases, salicylate of soda (wintergreen) will bring them to a termi- 
nation sooner than any other measure. For a child three years 
of age two grains of the salicylate of soda may be given every two 
hours, with four grains of the bicarbonate of soda — five doses being 
given in twenty-four hours. After this age from three to four 
grains of the salicylate may be given at a dose — from twelve to 
twenty-four grains in twenty-four hours. Certain children appear 
to be predisposed to urticaria and give a history of having had 
several attacks. Children who suffer from persistent intestinal in- 
digestion are very Hable to recurrent attacks, which are sometimes 
very obstinate in character. 



IMPETIGO CONTAGIOSA. PEMPHIGUS 43 1 



IMPETIGO CONTAGIOSA 

This disease is dependent upon a localized skin infection. It 
is contagious, several children in the same family or school often 
having the disease at the same time. I have known one school- 
child to infect an entire class of twenty. Cases of impetigo are 
seen almost daily in out-patient work. There are no constitutional 
symptoms, there is rarely any itching, the only evidence of the 
disease being disfigurement of the skin occasioned by the dry, 
adherent crusts. The encrusted areas may be isolated or they may 
coalesce, forming large masses. 

Treatment. — The most satisfactory treatment with me has been 
to soften the crusts with sterilized olive oil applied on gauze, 
the gauze having first been saturated with the oil. The oil-soaked 
gauze is then bound to the parts. Usually in twenty-four hours 
the crusts may readily be removed. Afterward an ointment com- 
posed of 10 percent boric acid in ungt. aquae rosae, or one composed 
of 10 percent ichthyol in vaselin, should be applied on sterile gauze 
and bound to the suppurating surface. The dressing should be 
changed at least night and morning. Recovery is usually complete 
in from two to three days. W^hen the crusts are on the Hps or 
other portions of the face where the dressing described cannot readily 
be applied, they should be kept moist with either the boric acid or 
ichtM^ol ointment. Fresh ointment should be applied at least every 
three hours, both before and after the crusts are removed, if treated 
without the use of the gauze. 

PEMPHIGUS 

Pemphigus in the newly born is an infection of the skin mani- 
festing itself in a bullous eruption which may appear on any portion 
of the skin surface. An epidemic of pemphigus occurred a few years 
ago in the New York Infant Asylum. The patients were mostly 
well-nourished infants, and nearly all that wxre born during a 
period of four weeks, twenty-six in number, developed the disease. 
The blebs varied in size from one-eighth to one -half inch in diameter 
and were filled with light yellow serum. The examination of the 
serum showed uniformly a pure culture of the staphylococcus 
albus. 

Treatment. — The management consisted in opening the blebs and 
in the application of various antiseptic solutions and ointments. 
Not much improvement followed the treatment, nothing worthy of 
note being discovered until creolin baths were used. This treatment 
not only relieved those cases which had developed, but the systematic 
bathing in a i percent creolin solution of all the newly born in the 
institution prevented the spread of the infection. 



432 DISKASKS OF THE SKIN 

In two cases seen by me in consultation, pemphigus was asso- 
ciated with a marked syphilitic infection. The patients lived in the 
country, at a considerable distance from New York City, and facilities 
for taking the serum for examination were not at hand. In a general 
way the infants presented the same clinical appearance to the above, 
with the exception that the syphilitic cases were much more severe. 
There was fever, with considerable dermatitis. The blebs also 
were present on the palms of the hands and soles of the feet, 
which was not the case in the simple staphylococcus cases. Both 
the syphilitic cases terminated fatally within twenty-four hours after 
my visit. 

ERYTHEMA NODOSUM 

Erythema nodosum is characterized by the formation in the 
skin and subcutaneous connective tissue of multiple brownish 
nodules of varying size. They are most frequently seen over the 
anterior surface of the leg, less frequently posteriorly. They are 
exceedingly painful to the touch. In two of my cases they were 
associated with peliosis rheumatica, and all were in rheumatic 
subjects. Pigmentation follows the disappearance of the nodules. 
There is usually moderate fever and the child complains of general 
soreness and pain throughout the body, in addition to the pain 
caused by the nodules. 

Treatment. — The patient should be kept in bed until the acute 
febrile period is passed and the nodules begin to disappear. The 
treatment is begun with the administration of one or two grains 
of calomel followed by a saline laxative. As the disease is probably 
one of the many protean manifestations of rheumatism, it should be 
treated as to diet and medication according to the suggestions laid 
down in the section on Rheumatism. The most satisfactory local 
measure for the relief of pain is the lead and opium solution, U. S. P. 
Soft old linen or gauze is moistened with the warm solution and 
applied to the parts, over which oiled silk or rubber tissue is placed 
to prevent too rapid evaporation and held in position by ban- 
dages. 

Illustrative Case. — The patient, a delicate young girl, had three 
crops of nodules, the different crops having appeared at intervals 
of about three months. The first attack was associated with peliosis 
and urticaria. The treatment which I had employed successfully 
previous to this case was that of the salicylate and bicarbonate 
of soda and antirheumatic diet. This patient, who is markedly 
rheumatic, had taken large quantities of the salicylate, and its 
readministration had no effect; but the nodules began to diminish 
and disappeared completely in all three attacks under the admin- 
istration of thirty grains daily of iodid of potash. 



l^RYTHKMA MULTIFORME. RHUS POISONING; IVY POISON 433 

The duration of my cases has been from ten days to three weeks, 
with the exception of the one referred to, which persisted for six 
weeks, or until the iodid was brought into use, when the improve- 
ment was prompt. 

ERYTHEMA MULTIFORME 

As its name indicates, this disease manifests itself in many differ- 
ent forms. There may be reddened papules, macules, and erythema- 
tous areas, all of which are most frequently found over the dorsal 
surfaces. In children there are usually associated disturbing dis- 
orders of digestion. Children of rheumatic inheritance are the most 
frequent sufferers. The condition is often confused with urticaria. As 
a result of the infiltration into the skin, the lesion of erythema mul- 
tiforme requires several days for resolution to take place, while the 
lesions in urticaria are very transient in character, rapidly appearing 
and disappearing. In erythema there is usually very little itching. 

The treatment consists in relieving the constipation, or whatever 
digestive disorder may exist, and the use of salicylate of soda ; for a 
child five years of age, from eight to twelve grains daily should be 
given, in divided doses after meals. In case there is itching or irri- 
tation of the parts, an ointment composed of menthol, ten grains to 
one ounce of ungt. aquae rosae, will usually furnish relief. The erup- 
tion seldom lasts longer than a week. A pigmented area may re- 
main at the site of the lesion. 

RHUS POISONING? IVY POISON 

Contact with Rhus toxicodendron produces in many people a 
most active dermatitis. There is marked burning with considerable 
itching of the involved surface. There may be a simple erythema, 
but usually there are small vesicles and bullae filled with serum, which, 
if they become infected, form pustules with the possibility of mul- 
tiple abscesses. When the face is involved, great disfigurement 
ma}^ result. 

I have used various measures from time to time in the treat- 
ment of this form of dermatitis. For the acute stage — the period 
of itching, burning, and edema — there is no better remedy than 
the fluidextract of Grindelia rohusta — one to one and one-half 
drams to the pint of water. In the very acute cases one dram 
would better be used at first. It is best applied on lint or soft old 
linen as a wet dressing. The solution should be used cold and re- 
newed every fifteen to thirty minutes. During the stage of resolution 
a saturated solution of boric acid may be used in the same way, or, 
what is more convenient, an ointment composed of 5 percent boric 
acid in ungt. aquae rosae. This is apphed to the parts on linen, 
after which resolution usually takes place promptly. When pus- 
28 



434 DISEASES OF THE SKIN 

tules develop they must be opened and the parts treated with a 
wet dressing of a saturated solution of boric acid. 

FURUNCULOSIS; BOILS 

Boils are frequently seen in deHcate, poorly nourished children, 
and are usually due to the inoculation of the skin with the staphy- 
lococcus. There is no evidence of any abnormal constitutional 
state other than malnutrition. The boils occasionally develop 
in well babies. Under proper management there will be a crop or 
two, but perhaps not over five or six boils in all. In marasmic 
cases, in hospital work, I have opened over one hundred on one 
patient in caring for the successive crops as they appeared. 

Treatment. — Local. — When pus is evident in the boil, a free in- 
cision should be made and the pus expressed. The skin about the 
wound should be washed vigorously with tincture of green soap 
or ordinary soap and water. Applying a few drops of a solu- 
tion of bichlorid of mercury is of little or no value. This in 
itself will not be sufficient to prevent a reinfection; as some pus 
invariably escapes upon the surrounding healthy skin when many 
boils are opened. A wet disinfectant dressing or a disinfectant 
ointment should follow incision and cleansing. Bichlorid dress- 
ings are to be used only temporarily in children. The dressing 
which has appeared best to prevent the spread of the infection 
is a saturated solution of boric acid, which is used on gauze or 
lint, when the involved area is not too large. In a marantic child, 
when a considerable portion of the surface over the trunk or thorax 
needs to be covered, the repeated renewal of the solution causes 
a reduction in temperature which is not desirable. In such infants, 
and in out-patient work where a wet dressing cannot be used, an 
ointment of 15 percent boric acid in vaselin is thickly spread on 
lint and applied to the wound and for a considerable distance about 
it. The dressing should be changed every six hours. Ichthyol 
is of little service when used in a strength of less than 20 percent. 
The odor is disagreeable, it stains the skin and the clothing and 
controls the condition no better than does the boric acid ointment. 
Another advantage is that the latter is comparatively inexpensive. 
With fat children, who sometimes develop boils on the abraded 
surfaces at the folds of the neck or the nates, and in children who 
perspire freely, I have used a dusting-powder composed as follows: 

I^. Pulveris acidi borici o j 

Pulveris amyli 

Pulveris zinci oxidi aa oiss 

M. Sig. — Dusting-powder. 

This is applied as soon as the wound is closed, and the parts are 
kept dry with it. (See Vaccine therapy, page 527.) 

Constitutional. — The constitutional treatment is important. If 



SCABIKS; ITCH. BED-SORES ; DECUBITUS 435 

the child is marasmic or if he has malnutrition, suggestions found 
under those headings should be brought into use. In the many 
cases I have treated, internal medication other than that directed 
toward the improvement of the general constitutional condition 
has been without value. The sulphid of calcium and other drugs 
which are supposed to have a direct influence upon the condition 
have proved of no service. They were not considered valueless 
because the patient did not recover, for if the patient is not too 
reduced in vitaHty he always recovers, regardless of the treatment. 
Observation on a series of cases of this type for which opportunity 
was afforded by institution work has shown that those treated with the 
sulphid of calcium, for example, made no greater progress than did 
those to whom it was not given. This line of treatment is an example 
of ''heredity in medicine." A remedy has been advocated by some 
one of consequence in the past. It is then handed down from gen- 
eration to generation by writers, many of whom, not having had 
opportunity to place observations of value behind their advocacy 
of the measure, have simply repeated what has been said by others. 

No matter how extensive the process, children with furunculosis 
may be bathed as in health. The water used for the bath should 
first be boiled, and in it bicarbonate of soda, one tablespoonful 
to the gallon, should be used. Of course, there should be little or 
no friction of the skin. 

SCABIES; ITCH 

Scabies is a contagious disease of the skin caused by the bur- 
rowing of the acarus scabiei. The disease is seen with considerable 
frequency among out-patient children. The cases dift'er greatly 
in severity, but, in all, the treatment is practically the same, vary- 
ing only as to the necessity of repeating or continuing it. At bed- 
time a hot bath is ordered, from 105° F. to 110° F. While in the 
bath the patient is vigorously scrubbed with a towel, using the 
yellow laundry soap. After the scrubbing he is dried vigorously 
and sulphur ointment, U. S. P., rubbed as vigorously into the skin. 
In forty-eight hours the process is repeated and again repeated 
forty-eight hours later. A repetition at twenty-four-hour intervals 
is usually too irritating to the. skin. The third treatment usually 
terminates the case. In quite young children, in whom the sulphur 
ointment may be too irritating, it may be diluted one-fourth or one- 
half by the addition of vaselin. This may be done with older chil- 
dren also if the first application produces considerable dermatitis. 
Care must be exercised in destroying, boihng, or disinfecting all 
clothing previously worn by the patient. 

BED-SORES? DECUBITUS 

During any illness with greatly disturbed nutrition, as in cerebro- 
spinal meningitis, typhoid fever, empyema, or in any prolonged 




436 DISKASBS OI^ THE SKIN 

illness with emaciation, constant pressure on the prominent bony 
parts interferes sufficiently with the circulation to cause destruction 

of the integument. The 

most frequent sites for 

/'' decubitus in children are 

the sacrum, the heels, and 
the back of the head. 

The condition is best 

prevented by cleanliness, 

both as to the patient and 

the bed- linen, and by 

keeping the latter smooth 

and frequently changing 

i the position of the patient. 

J The parts as they become 

/ sensitive and show redness 

^^ should be bathed several 

y times a day with alcohol. 

If this does not relieve the 

condition, the areas should 

Fig. 50.— Head-rest to Prevent Bed-sores. be COVered with diachyloU 

plaster so as completely 
to cover and protect the involved areas. The air-cushion or the 
water-bed may be necessary in any prolonged illness. 

When the back of the head is involved, the scalp should be 
shaved and the head allowed to lie in a home-made head-rest 
which is constructed as follows (Fig. 50) : A piece of fairly stiff 
wrapping-paper, four inches wide, is twisted into a rope, of which 
a circle four to five inches in diameter is made by bringing the ends 
together. The paper is then wrapped thickly with absorbent cotton, 
which is in turn wrapped with a two-inch roller bandage. 

PEDICULI 

Head lice, or pediculi capitis, are very frequently seen in out- 
patient and hospital work among children in all the larger cities. 
Occasionally children become infected in school or in public convey- 
ances, and carry the vermin to other members of the family. 

The most successful and cleanly treatment consists in cutting the 
hair short; this done, wash the head with soap and water twice a 
day, and after drying moisten the scalp thoroughly with the following 
solution, daily: 

I^. Acidi acetici 5ij 

JJtheris sulphurici §iij 

Tincturse delphinii 

Spiriti vini rectificati aa § iv 

Improvement will follow a few treatments. The pediculi will be 
killed and the nits may be removed with a fine-tooth comb. If the 



TiNKA tonsurans; ring- worm of the scalp 437 

patient is a girl, it is not absolutely necessary to sacrifice the hair. 
It may be parted from various portions of the scalp and the solution 
applied without previous washing. However, if the hair is not cut, a 
much longer time will be required to effect a cure. 

TINEA TONSURANS? RING-WORM OF THE SCALP 
Ring-worm of the scalp due to the action of the trichophyton 
tonsurans is of frequent occurrence, and on account of its conta- 
gious nature is a disease greatly dreaded in institutions for children. 
An epidemic once started is only with the greatest difficulty eradi- 
cated. The appearance of the scalp is characteristic. Beginning 
with a few small vesicles, the process extends from the periphery 
outward, showing the scaly desquamating scalp, and the short stubby 
hairs broken at their points of exit from the scalp. There may be 
but one area involved or there may be a dozen. I have seen almost 
complete baldness result from the coalescence of many of these areas. 
Treatment. — Cures are difficult and the treatment must be along 
radical lines. In an epidemic several years ago at the Country Branch 
of the New York Infant Asylum, abundant opportunity was offered 
to test various measures of treatment that had been advocated by 
different observers. Among others were chrysarobin in various 
combinations, carbolic acid, iodin, bichlorid of mercury, sulphur, 
and white precipitate. As a result of much experimentation, a 
useful scheme of management was established, the report of which 
may be found in "The New York Medical Journal," of October lo, 
1891. 

The location of the fungus in the hair-follicle makes it very diffi- 
cult to apply any drug so that it will be effective as a parasiticide. 
In order to accomplish this, it is absolutely necessary to cut the hair 
of the entire scalp as short as possible. Upon beginning the treat- 
ment the scalp is thoroughly scrubbed with soap and water, using 
the strongly alkaline yellow laundry soap so as to remove all the 
dead hair and desquamated epithelium. The parasiticide to be 
used is then rubbed into the diseased area and for a considerable 
distance on the surrounding healthy scalp. The parasiticide which 
answered best with us was composed of bichlorid of mercury two 
grains in one-half ounce of equal parts of olive oil and kerosene. 
The bichlorid must be dissolved in a small quantity of alcohol before 
it is added to the oil mixture. This is rubbed into the diseased area 
every day until the scalp becomes sore and tender. In order to 
prevent the spread of the infection to other parts, the solution may 
be applied every fourth day, without friction, to the entire scalp. It 
is necessary in order to effect a prompt cure to produce a dermatitis 
at the site of the lesion. When this occurs the treatment is tempo- 
rarily discontinued. When the inflammation subsides another is 
produced in like manner. After three or four weeks of this treatment 



438 DISK ASKS OF THK SKIN 

it may be discontinued and the parts kept under observation in 
order to note the results. A daily application of sterile oil aids in 
bringing the skin to a normal condition. 

In one-third of the children in the epidemic referred to, two grains 
of the bichlorid of mercury were added to one ounce of the tincture 
of iodin. Twenty-six cases were treated by this method with an 
average duration of treatment of eight and one-half weeks. Several 
recovered in four weeks, while in others twelve weeks of treatment 
were necessary before it could be discontinued. While the treatment 
is under way the child should wear a cap, day and night. This may 
be made of any cheap, light-weight material, which after a day or 
two of use may be burned. Cheese-cloth caps were used in our 
cases. Rubber gloves were necessary to protect the hands of the 
nurse who made the applications, especially if there were many heads 
to be treated. 

The epidemic, which included at least one hundred cases, was 
controlled by the above means and prophylaxis resulted from the 
use of the kerosene and olive oil without the bichlorid. It was 
found impossible to maintain a quarantine permanently or effectu- 
ally even for a short time, particularly during the warmer months, 
therefore every inmate of the asylum of the "runabout" age who 
did not have the disease was treated as though he was expected to 
get it. Every head was "clipped" and the hair kept short. Twice 
a week they were given a kerosene and olive oil shampoo. 

In private work the continued use of kerosene and olive oil is not 
popular for reasons readily understood. In such cases the hair is 
clipped as soon as the case is diagnosed and a kerosene shampoo 
given. The bichlorid of mercury, two grains to one ounce of tincture 
of iodin, U. S. P., is applied to the parts with sufhcient vigor to 
produce a dermatitis. If the disease shows a tendency to spread on 
the scalp beyond the original site it is best prevented by the use of 
the kerosene and olive oil, as above suggested. 

TINEA CIRCINATA 
Ring- worm is produced by the vegetable parasite, trichophyton. 
It may develop upon any portion of the skin surface. The treat- 
ment is the use of some irritant that will produce a desquamation 
of the epidermis in the superficial layers of which the parasite is 
located. The tincture of iodin has proved a satisfactory remedy if 
the disease is located where its use is possible. Two or three 
applications of the U. S. P. tincture is all the treatment that is 
ordinarily required. If the case is at all obstinate, two grains of 
bichlorid of mercury may be added to the ounce of the tincture of 
iodin. If the lesion is situated on an exposed surface such as the 
face, five grains of bichlorid of mercury may be dissolved in equal 
parts of alcohol and glycerin and applied locally. 



miliaria; prickly hkat 439 



MILIARIA? PRICKLY HEAT 

In prickly heat there is an acute engorgement of the vessels of 
the sweat-glands with obstruction of their outlets. Minute papules 
form which are reddish in color. The mild cases are without inflam- 
mation. When inflammation develops, small vesicles also appear, 
and may cover large areas of the body. Nearly every infant suffers 
from prickly heat in the summer. It is most frequentl}^ seen on the 
head and neck and over the chest and shoulders. The patients are 
very uncomfortable and restless. There is evidently a great deal 
of burning and itching. The condition is caused by heat, due either 
to too much clothing or to the hot weather of summer; both causes 
may be operative. I have frequently seen it in winter in overclad 
children. Most babies are overclad at all seasons of the year. When 
prickly heat develops, regardless of the season, it is a sure sign that 
the child has been kept too w^arm. The duration of the miliaria is 
dependent upon climatic conditions and also upon the treatment. I 
have seen cases which existed for months. 

Treatment. — Heavy clothing and flannels are to be avoided. In 
order to lessen the local irritation, the garment worn next to the skin 
ma}^ be lined with silk, linen, or gauze. The further means of manage- 
ment as regards both the relief afforded the patient and the cure of 
the condition, consists in the frequent application of cool water, in 
the form either of a tub-bath or sponging. The soda bath, the bran 
bath, and the starch bath (page 31) are all most useful. For pur- 
poses of sponging, a solution of bicarbonate of soda should be used 
— one tablespoonful to a gallon of water. The relief aft'orded the 
patient depends not so much upon what is used in the water as upon 
the fact that plenty of cool water comes in contact with the itching, 
burning skin. Ointments and salves are of little service here, as 
they tend to produce further maceration of the skin. As local appli- 
cations, powders are preferred to lotions. A powder used with satis- 
faction in this condition is of the following composition: 

I^. Acidi salicylici gr. x 

Acidi borici gr. Ix 

Pulveris amyli 

Pulveris zinci oxidi aa § j 

This is to be dusted freely over the involved surface several 
times daily, every hour if necessary. In case irritation is produced 
by the salicylic acid it may be omitted or its strength may be de- 
creased by the addition of powdered starch. 



DISEASES OF THE EAR 

EARACHE 

In every case of earache in an infant or young child the ear-drum 
should be examined. It may show intense congestion and bulging, 
requiring immediate incision, or there may be but slight congestion 
about the periphery of the drum and at the tip of the malleus. 
When the latter condition exists there are various means of relieving 
the pain, the most effectual application of drugs being probably 
instillation into the ear of equal parts of a 4 percent solution of cocain 
and camphor- water ; five drops of the warm solution are dropped 
into the ear and repeated every half hour if necessary; after which 
dry heat may be applied by the use of a hot-water bottle or a salt 
bag. I have frequently reHeved severe attacks of earache by means 
of a hot- water douche — one pint of water at 110° F., using a douche- 
bag or a fountain syringe. When the pain is not promptly relieved 
the ear should be carefully watched, particularly if there are recur- 
rent shooting pains, a throbbing sensation, or a feeling of fullness 
in the ear. In young children a rise in temperature associated 
with earache is often indicative of an acute infectious process in 
the middle ear, and, in addition to the treatment suggested, the ear 
should frequently be examined, in order to be prepared for early 
incision of the drum membrane should it be required. 

ACUTE OTITIS 
Acute otitis rarely occurs in infants and children as an inde- 
pendent affection, but is usually a complication of, or a sequela 
of some infectious disease. Among my own patients a great majority 
of cases occurred in association with or following an acute inflam- 
matory condition of the upper respiratory tract due to a mixed 
infection — a condition which occurs in many of the illnesses of 
infancy and early childhood; thus, it not infrequently follows 
simple rhinitis, pharyngitis, tonsillitis, grippe, measles, or scarlet 
fever. The disease is of much more frequent occurrence in children 
than in adults. The younger the child, the greater the apparent 
susceptibility. This susceptibility in the young is due chiefly to 
three causes: the comparatively patent eustachian tube, the ten- 
dency to inflammatory conditions of the throat, and the presence 
of adenoid growths in the pharyngeal vault — features favorable 
to the development of infection and for its extension to the cavity 

of the middle ear. 

440 



ACUTE OTITIS 441 

Otitis in young children is probably more frequently overlooked 
by the practitioner than any other disease of childhood. This is 
through no fault of his own, unless it be a fault to omit to examine 
the ear-drums when the patient has fever ; it is because of its indefinite 
manifestations, and the faulty teachings of text-books as to the symp- 
tomatology of the disease. In a search of many works on otology, 
I find that the symptoms as laid down are dependent almost ex- 
clusively upon evidences of pain — earache — the pain being com- 
plained of by older children or manifested in the very young by 
vigorous crying, by tossing the head from side to side, by head- 
rolling, ear-tugging, crying out in sleep, disinclination to rest the 
head on the affected side, pain upon manipulation of the ear — in 
short, we have been taught that there is invariably some manifesta- 
tion of pain referable to the ear or the adjacent structures in all 
cases of acute otitis in infants and young children. 

Illustrative Cases. — ^What symptom is most frequently associated 
with otitis in children? In seventy-two private cases one symptom, 
and only one, was present in all — fever. The otitis was apparently 
primary in three. In these the condition did not follow and was not 
associated with any previous abnormal state, as far as we were able 
to judge. One was associated with or followed German measles ; two, 
scarlet fever; seven, measles; and fifty-eight, grippe or catarrhal 
colds. In the cases in which the otitis followed, but was not immedi- 
ately associated with any of the preceding diseases, which was the rule 
in the majority of the cases, there was nothing especially character- 
istic in the temperature range. In some there were the morning 
drop and the evening rise; in the others there was no regularity as 
regards the temperature range. With but few exceptions the 
otitis developed during convalescence from an acute process else- 
where, the ear involvement being suspected because of a persistent 
elevation of the temperature for which no other cause could be 
discovered. The fact that fifty-eight of the cases, or 81.5 percent, 
occurred with or followed non-specific, inflammatory conditions of 
the upper respiratory tract, such as tonsillitis, grippe, and catarrhal 
colds, emphasizes the necessity for frequent aural examinations 
during or following such disorders, particularly when there is an 
elevation of the temperature — a temperature which, in the absence 
of definite clinical signs, we are apt possibly to attribute to chronic 
grippe, malaria, typhoid fever, or dentition. 

The most interesting factor in this series of cases was the absence 
of pain or localized tenderness on manipulation in fifty of the cases, 
or 69 percent. Among those included in the pain group, twenty- 
two in number, there are some which perhaps should not be so 
included. In these there were no signs of pain, as we generally 
expect to find it; but in this group are included those who were 
very restless, who slept poorly, and those who showed evidence of 



442 



DISEASES OF THE EAR 



any great discomfort. Upon discovering the ear disease and noting 
the reHef which followed incision of the drum membrane, it was 
fair to assume that the source of the previous discomfort was the 
ear. Had we depended for the usual signs of pain or local tenderness, 
in fifty of the cases a diagnosis of otitis at the time would have been 
impossible. Six were seen in consultation, because of the unex- 
plained, continued fever. Nine had been treated by other physicians 
who had failed to discover the cause of the continued fever. In 



G 






Fig. 51.— Hard-rubber Ear Syringe, 




none of these had ear involvement been suspected, because of the 
absence of pain and localized signs. 

Treatment. — Operative. — Every practitioner who has children for 
his patients should be sufficiently familiar with the landmarks of the 
normal drum membrane at the various ages of early life to differen- 
tiate the normal from the abnormal. In the routine examination of 
the child, the ear should be included in all 
conditions associated with angina or fever. 
In quite young babies an otoscopic examina- 
tion may show a dull whitish-appearing drum 
membrane which on a superficial examination 
of the case might be ignored. In all cases, 
particularly at this age, when the drum land- 
marks are indistinct, a cotton-pointed probe 
should be brushed over the surface, thus re- 
moving the epithelial scales which may have 
lodged there, when perhaps a congested, bulg- 
ing membrane may be revealed. This point 
was brought out by Dr. J. F. McKernon 
in January, 1899, in a discussion before the 
State Medical Society at Albany. 

Conditions or appearances of the drum 
membrane which require incision are often 
difficult of recognition by those not skilled in 
otoscopy. When the drum is bulging, deeply 
congested in appearance, with landmarks indistinct, an incision is 
necessary, and should be made in the posterior portion of the drum, 
beginning low down and extending upward through Shrapnell's mem- 
brane. When also there is congestion of the drum membrane over 
the tubal entrance, when the congestion extends toward the periphery 
with indistinct landmarks without bulging, incision is indicated. 




Fig. 52.— Soft-rubber Ear 
Syringe. 



ACUTE OTITIS 443 

Post-Operative. — The after-treatment following incision consists in 
syringing the ear at three-hour intervals with eight ounces of a 
I : 10,000 solution of bichlorid of mercury for three or four days, when 
the syringing may usually be practised at intervals of from four to 
five hours until the drum closes. In very 3^oung infants if the bi- 
chlorid causes a dermatitis at the meatus, it is well to change to a 
sterile normal salt solution, using the same quantity of fluid. In 
those cases in which only serum is present at the time of operation, 
a closure in ten days may be expected ; if, however, pus is present, 
from two to three weeks will be required. A sudden stopping of 
the discharge usually means that the opening in the drum is closed, 




Fig. 53.— Syringing the Ear. 

either through plugging of the opening with thick pus or because 
of the too early heaHng of the drum : in either event a reestablish- 
ment of the discharge is required by removing the obstruction or 
by reincision. The chief factors in prolonging the discharge are 
adenoids and a lowered state of physical resistance. After syring- 
ing, the ear should be carefully dried with absorbent cotton. For 
purposes of s^^inging, a one-ounce hard-rubber ear syringe with 
soft-rubber tip (Fig. 51) answers best. If this is not obtainable a 
douche-bag, at an elevation of not more than three feet above the 
patient's head, may be used. The douche-bag sometimes answers 
better for those who are unskilled, or a soft-rubber bulb syringe of a 



444 DISEASES OF THE EAR 

capacity of one to two ounces may be used (Fig. 52). The small 
double-current ear-irrigator may be used with advantage in that it 
largely prevents wetting the patient. With either method, the child 
rests on his back with his hands pinned to his side by means of a 
large bath towel, with a pus basin under the ear to catch the flow 
(Fig. 53). If the nurse can have an assistant, the upright position 
may be used. 

DEAFNESS 

Hearing is probably established in the newly born during the 
first two or three days of life. During the early months of life 
the hearing is very acute. Acquired deafness is not at all unusual, 
however, even in comparatively young children. Among its most 
frequent causes is an extension of an inflammation from the throat 
to the tubal mucous membrane. In diphtheria, in the exanthe- 
mata, in grippe, in tonsillitis, and in many other ailments of early 
life, there is an associated inflammation of the nasopharyngeal 
structures. Unless infection of the middle ear occurs, deafness 
is usually of a very temporary nature. Persistent deafness may 
be the result of enlarged tonsils, adenoids, or organized changes 
in the canal or in the middle ear. Among the most frequent causes 
of persistent deafness in children are adenoids, scarlet fever, and 
cerebrospinal meningitis. Congenital syphilis is rather an infre- 
quent cause of deafness. Response to treatment in this type is very 
satisfactory. Deafness at rare intervals follows an attack of mumps 
and is due to an involvement of the labyrinth, and calls for expert 
otologic treatment. 

Deaf children whose condition is not recognized are often accused 
of inattention and punished when they are slow in responding when 
spoken to. They make slow progress in school and are considered 
stupid. Many such children show defective hearing of a pronounced 
type, due usually to enlarged tonsils and adenoids. 

The management in these cases is to remove the adenoids and 
tonsils. When relief is not afforded by operation, the child should 
be taken to an aurist for a careful examination as to the condition 
of the ears and the hearing capacity. 

CHRONIC SUPPURATIVE OTITIS 
Not infrequently cases come under our care in which there is a 
purulent discharge from the ears, oftentimes most offensive, with 
a history that the discharge followed measles, scarlet fever, or grippe, 
and that it has continued for weeks or months. Examination may 
show a perforation of the upper portion of the drum, through which 
there is a free discharge, but on account of the site of the perfora- 
tion not sufficient to drain completely the middle-ear cavity; or 
there may be only a small perforation, too low for effective drainage. 



MASTOIDITIS 445 

In either case incision should be made and free drainage established. 
The ear should then be syringed (Fig. 53) at least three times a day 
with a I : 10,000 bichlorid solution. In cases of chronic suppurative 
otitis it is well to examine for adenoids, as these growths in the 
nasopharyngeal vault will help to keep up the discharge indefinitely. 
The presence of dead bone and granulations is also to be considered 
in the chronic suppurative cases. When the presence of dead bone 
or granulations is established, it calls for radical operative pro- 
cedures by a skilled otologist in order to avoid mastoid and intra- 
cranial complications. 

MASTOIDITIS 
It is not necessary to wait for swelHng in the post-auricular 
region, or pain or tenderness over the mastoid in order to make 
a diagnosis of mastoid disease. The child may object quite as 
strongly to pressure on the unaffected side or to pressure elsewhere 
on the skull, which completely negatives w^hat one might hope to 
elicit by tenderness. Involvement of the mastoid cells may be 
looked for in any case in which there is pus in the middle ear. A 
daily elevation of the temperature in purulent otitis with a freely 
discharging ear is very suggestive of mastoiditis, particularly if 
there is no other readily assignable cause for the fever. The further 
signs, continued fever with prolapse of the posterior superior wall 
of the canal, with the canal rapidly filling with pus after syringing, 
mean that mastoiditis is almost sure to be present and operation 
is indicated. With tumefaction and swelling of the soft parts be- 
hind the ear — the so-called perimastoiditis — the mastoid cells and 
antrum will almost invariably be found involved and the radical 
mastoid operation should be performed. 



GLANDULAR DISEASES 

ACUTE ADENITIS 
The management of acute adenitis in a child depends to a cer- 
tain extent upon the age of the child and the factors producing 
the adenitis. One thing is to be remembered, however, in the 
treatment. It is this: The constant appHcation of an ice-bag will 
do more toward controUing the adenitis and preventing complica- 
tions than will any other measure which we possess. Unfortunately, 
in infants and in a few young children, it is not practicable, being 
particularly difficult when, as is generally the case, the cervical 
glands are involved, since it is then almost impossible to keep the 
ice-bag in place. In older children, after the second year, it should 
be applied continuously day and night. Where ice cannot be used, 
the cold compress (page 333) is brought into use, a most valuable 
procedure. Or I apply cataplasma kaolini as follows : A piece of 
linen, sufficiently large to cover the swollen area, is thickly covered 
with the paste and applied to the parts. A fresh appHcation should 
be made every six hours. The following ointment may be used : 

I^. Ichthyoli 5iiss 

Unguenti zinci oxidi q. s. ad S j 

The ointment is applied freely on linen, which is covered with 
oiled silk and held in position by a suitable bandage. Many mothers 
find it more convenient to use a cap made of cheese-cloth, which 
covers the dressing and holds it in place. The ichthyol ointment 
should be freshly applied every six hours. In cases where other 
measures have been unsatisfactory, I have used successfully Crede's 
ointment, fifteen grains of which are rubbed into the swollen areas 
twice daily. 

Not only is it necessary to treat adenitis locally, but the source 
of the infection must be sought for and if possible eradicated. In 
cervical adenitis the source of the infection is in the mouth, the throat, 
or on the scalp. Decayed teeth, enlarged tonsils, and adenoids will 
probably require attention. So also acute tonsilHtis and diphtheria, 
the anginas of grippe and the exanthemata, are conditions any one 
of which may cause cervical adenitis, which is usually due to a mixed 
infection. PedicuH capitis is a frequent cause of post-cervical 
adenitis. The majority of my cases which have gone on to suppura- 
tion have been either a pure streptococcus infection or the strepto- 
coccus was the most prominent. Such infections may take place 
with any of the acute infectious diseases, but they are most frequently 
met with in scarlet fever. In inguinal adenitis, balanitis in boys or 
vulvovaginitis in girls is usually the source of the infection. 

446 



PERSISTENT ADENITIS 447 

Even when the ice-bag is appHed with the first suggestion of 
swelHng and used faithfully, the cases of streptococcus infection 
sometimes go on to suppuration. Repeatedly I have seen the aden- 
itis, which is often an early compHcation of diphtheria, disappear 
quickly after full doses of diphtheria antitoxin. Acute adenitis ter- 
minates in one of three ways — resolution, suppuration, or persistent 
adenitis. When the swelling softens, we know that suppuration has 
taken place, and our only treatment is to incise freely, allowing the 
pus to escape, and place in the wound a strip of sterilized gauze 
to assist in drainage and to prevent too early a closure of the incision. 
The wound should be dressed once daily. Extirpation of the dis- 
eased gland is not to be advised until later, if at all. In fact, a greater 
part or all of the gland tissue may have undergone suppuration, 
producing complete destruction. 

PERSISTENT ADENITIS 

After an acute adenitis, in a small percentage of cases, the gland 
or glands will remain persistently enlarged, so as to constitute a defor- 
mity, or the deformity may be the result of a series of acute attacks, 
each leaving the gland a little larger than before. Whether these 
glands are tuberculous from the outset or become so later, it is im- 
possible to state. I know, however, from an observ^ation of several 
cases, that many of those which do not show the distinctive character- 
istics of tuberculous adenitis which we have been taught to expect, do 
show that they are tuberculous upon examination after operation — 
the glands having been removed because of the unsightly deformity ; 
I have, therefore, come to look upon pronounced persistent adenitis 
as probably of tuberculous origin, even though but two or three 
glands appear to be involved. Because these chronically enlarged 
glands sometimes undergo resolution without suppuration does not 
prove the absence of tubercle bacilli. 

Treatment. — I have treated these cases of persistent adenitis with 
electricity, massage, drugs, and local applications, but am unable to 
advise the use of any one of them, nor have the iodids in my hands 
been of any appreciable value. Constitutional means, of course, 
should be employed — iron, cod-Hver oil, and the hypophosphites 
being prescribed if the child's condition appears to require them. In 
many cases, however, such treatment is not called for, as the chil- 
dren are in perfect condition, the process being entirely a local one. 
I have had no experience with the "jc-ray" and various ''light" 
methods of treatment which are advocated by some writers. My 
own observation in the management of these cases has been that 
when the glands remain for several weeks sufficiently large to pro- 
duce a deformity, remoA^al by surgical means is the onlv course to 
pursue. The operation is a simple one, is quickly performed, and 
need leave but a very slight scar. 



448 GLANDULAR DISE^ASES 



ADENOIDS 

By the term "adenoids" is understood a hypertrophy of the 
mucous glands of the nasopharyngeal vault. They may be associated 
with an enlargement of the tonsils, or be entirely independent of it. 

The growths vary in consistency from friable, sponge-like tissue 
filled with blood, to those composed largely of firm connective 
tissue. The age of the child appears to exert but little influ- 
ence upon the character of the growth. I have removed hard, 
firmly organized growths from children of eighteen months and two 
years, and soft, sponge-like masses from children seven or eight 
years of age. The amount of growth varies also, from a slight 
fringe of hypertrophied glands situated high up on the posterior 
pharyngeal wall, to a large mass which completely fills the naso- 
pharyngeal vault. 

Adenoids may occur at any age, but are more common in children 
from two to six years of age. The youngest case I have operated on 
was six months of age. Cases of congenital adenoids have been re- 
ported. Some children have large, roomy, nasopharyngeal vaults; 
while in others, on account of the high palatal arch and the promi- 
nence of the bodies of the cervical vertebrae, the space is very small. 
In such cases a very small amount of adenoid tissue causes marked 
obstruction. 

The symptoms vary according to the character and the amount 
of the growth. With a small growth in a roomy vault, there is apt 
to be a history of a nasal discharge which is usually regarded as a 
chronic ** cold." Many of these cases with a small amount of actively 
secreting adenoid tissue have most persistent coughs (page 268), which 
are worse when the child lies down. There may be nothing more than 
a clearing of the throat ; usually, however, the cough is more or less 
persistent. Now and then it is paroxysmal, and so closely resembles 
whooping-cough that an error in diagnosis is often made. Such 
cases oftentimes pass unrecognized. The presence of adenoids is 
not suspected because breathing is unobstructed, the cough being 
attributed to the stomach, to dentition, to nervousness, etc. When 
there is a decided obstruction to breathing, whether due to a large 
growth or to a small palatal vault, the characteristic signs are sure 
to be present: The open mouth, the snoring at night, the stupid 
expression, the disturbed articulation, the persistent nasal dis- 
charge, the deafness, the inability to blow the nose, the cough, 
and the story of chronicity, — all combine to make a picture which 
can be produced by no other condition. No special class or type 
of child is affected. We find adenoids not only in the delicate and 
ailing, but also in the strong and well. Out of hundreds of cases, 
I have seen very few in which lymphatism could be accused of 
having any part in the production of the growths. 



ADENOIDS 449 

When to Operate. — The management is operative in every case 
in which the growth produces symptoms which compromise the heahh 
and comfort of the patient. Early infancy is no contraindication to 
operation, if the conditions are sufficiently urgent. Fortunately, the 
necessity for a radical operation in the very young, that is, in those 
under one year of age, is extremely rare. These little patients, how- 
ever, may have growths sufficient to cause an obstruction, which 
gives rise to mouth-breathing, to difficulty in nursing, and to a very 
annoying and persistent nasal discharge. 

Operation for Temporary Relief. — In several instances I have 
relieved these cases temporarily by crushing the growths with the 
clean index-finger, the top of which is wrapped in a couple of layers 
of sterile gauze. At this age the adenoid tissue is usually very 
soft and friable. The finger-nail should be cut very short and the 
whole hand thoroughly scrubbed and disinfected. The child is 
wrapped and pinned, usually in a large towel, so that the arms are con- 
fined to its sides, and is then placed on its back on the bed or table. A 
clean towel for wiping away the blood should be placed under the 
head. The mother and nurse should be advised that a slight bleed- 
ing is expected. With the child thus in position, the physician 
holds the mouth open with a spoon or tongue depressor, and passes 
the clean index-finger of the right hand backward into the vault 
and easily breaks up the soft, spongy growth which may be present. 
The adenoids are by no means removed by this method, but their 
continuity is destroyed and portions of the growth doubtless slough 
off, thus affording temporary relief. The child will be able to nurse 
without inconvenience and the nasal discharge will stop. Opera- 
tion, however, is thus only deferred until the patient is older. In six 
months or a year the symptoms will return. 

Operation for Permanent Relief. — The only permanent rehef Hes 
in a curettage of the vault, and even with a complete removal of the 
growth by curettage and forceps, there may be a return if the opera- 
tion is performed on the very young — those under two years of 
age. When asked by parents if there is danger of a return of 
the growth, I always reply that a return is possible, and may 
take place in a small percentage of the cases. The older the child 
at the time of the operation, the less the liability of a recurrence. 
The possibility or probability of a return is no argument against 
the removal of the growths in the very young, for by the time the 
child is three or four years of age, a great deal of permanent harm 
may have resulted. 

As operation is the only method of treatment, it is one with 
which the general practitioner should by all means familiarize him- 
self. The operation is not performed by all alike. Some prefer 
the sitting position without an anesthetic ; others employ anesthesia 
and raise the patient to a sitting position at the time of the opera- 
29 



450 GIvANDULAR DISBASKS 

tion. It is my opinion that an anesthetic should be used in every 
case, unless contraindicated by some such condition as lymphatism or 
cardiac or kidney disease, which might make the anesthesia danger- 
ous. Regarding the choice of an anesthetic, my preference is to give 
nitrous oxid gas in children over two years of age to produce uncon- 
sciousness, and then substitute ether. This method is far more 
agreeable to the patient than when ether is used from the beginning. 
Primary anesthesia is all that is required. In the very young, 
when gas is not permissible on account of producing cyanosis, 
ether alone may be used. Chloroform I have learned to regard 
with much distrust. A boy three years of age upon whom I wa& 
to operate for adenoids came near dying under chloroform anes- 
thesia ; resuscitation was almost despaired of. With another child I 
had a similar experience. I have never experienced any unpleasant 
effects from ether during these operations. 





/ 



Fig. 54. — Position for Adenectomy and Tonsillotomy. 

If the operation is to be performed without an anesthetic the 
upright position is the best. The child's arms are bound to its 
sides with a large towel and fastened with safety-pins. He should 
be held on the lap on the right side of an attendant, who by cross- 
ing his legs confines the legs of the patient between his own. The 
attendant's right arm encircles the child while the left controls 
the head, which rests against his right shoulder. A basin should 
be within reach of the attendant, as the bleeding is sudden and 
profuse. 

If an anesthetic is used the child is placed on the table (Fig. 54) 
with the arms bound to its sides by a large towel or sheet. The 
Denhardt gag of the O'Dwyer intubation set is used to keep the 
jaws open. The growth should be located with the finger, and any 



RETROPHARYNGEAL ADENITIS 45 1 

adhesions which may be present should be broken up. If the tonsils 
are to be removed, that should first be done. As soon as the adenoids 
are removed, the patient is turned on his side so that the blood can 
drain into a basin which should be in readiness on a chair at the 
side of the operating table. Before removing the gag the operator 
should pass his finger into the vault to determine if it is clear; if 
not, the curet must again be brought into use. The Knight or 
McAuliffe forceps may be utilized in removing any shreds of tissue 
which may have been left behind. Two curets are usually necessary, 
a small and a larger one^ (Figs. 55 and 56). The operation can be 
more successfully performed if a curet is used in which the blade 
stands at an angle, as represented by the drawings. This allows a 
greater play of the cutting-blade in the vault. A moderate amount 
of blood is swallowed, which is usually vomited in the course of an 
hour or so. Parents should be told that this may occur. The child 
should be kept in bed for the remainder of the day on a reduced 



cv 




<m 




Figs. 55 and 56. — Adenoid Curets. 

diet of diluted milk, broths, and gruel. It is my custom to allow, 
four hours after the operation, three ounces of milk diluted with 
three ounces of water. A swallow of cold water or pieces of cracked 
ice can be given at any time. Following the operation I order 
for the nose an albolene spray, to be used three times daily for three 
weeks. 

Adhesions. — Three months after the operation the mother is 
asked to return with the child for examination. In several instances 
I have found that adhesions had formed between the cut surfaces and 
the soft palate, which had caused a return of some of the original 
symptoms. These adhesions are readily broken up with the finger, 
as are also any recurring growths which occasionally may be found. 

RETROPHARYNGEAL ADENITIS 

Retropharyngeal adenitis, as the name implies, is an inflamma- 
tion of one or more of the glands which are situated posterior to the 

iThe curets were made for the author by Geo. Ermold Co., 201 East 23d St., 
New York City. 



452 GLANDULAR DISEASES 

pharynx between the pharyngeal and prevertebral muscles. Pain 
and difficulty in swallowing are always present. Other symptoms 
are fever, — ioo° to 103° F., — and loss of appetite. The glands, as a 
rule, suppurate, forming a retropharyngeal abscess (see page 254). 
In an acute case an inspection of the throat will usually show a 
swelling at the right of the median Hne. If situated low down on 
the posterior pharyngeal wall, it may escape detection. Upon digital 
examination, instead of a smooth, fiat surface, the finger encounters 
an elevated, rounded mass, which should not be mistaken for an 
unduly prominent cervical vertebra. 

In retropharyngeal adenitis, while suppuration is the rule, it 
does not invariably follow. In one case, in a baby six months old, 
we waited for several days for the suppuration of the gland, which 
was greatly enlarged. This it failed to do, and the child recovered. 

In these cases treatment must be both local and constitutional. 
Local treatment consists in cleanHness. The mouth should be 
washed with a saturated solution of boric acid after each feeding. 
The use of iodids in adenitis in children I have found of questionable 
service. More is accomplished by a suitable diet and plenty of 
fresh air. 

TUBERCULOUS ADENITIS 

The only management of tuberculous adenitis which should 
be entertained is surgical — the removal of the diseased glands. 
After the operation the child should, if possible, be given the advan- 
tage of an outdoor life in the country, inland. These cases appear 
to improve most rapidly at an elevation of eight hundred feet or 
more. The diet should consist of meat, eggs, milk, and of high- 
proteid cereals, such as oatmeal and the dried legumes, given in 
the form of purees. It is my custom to order cod-liver oil and malt 
to be given in doses of from one teaspoonful to one tablespoonful 
after meals for one week, followed for one week by the syrup of the 
hypophosphites, when the oil and malt may be resumed for the same 
time, thus alternating indefinitely with the hypophosphites. If 
an examination of the blood shows that the patient is anemic, 
iron may be used in connection with the other remedies. The 
citrate of iron and the extractum ferri pomatum are well borne 
by the stomach and have appeared to be of considerable service 
in some of my cases. For children from five to ten years of age, 
one grain of the citrate of iron and quinin in sherry wine, or one 
grain of citrate of iron and ammonia in water, may be given after 
meals. The dose of extractum ferri pomatum at this age is one-half 
grain after each meal. 



HEREDITY AND ENVIRONMENT 

Many of the diseases, crimes, and failures of life are attributed 
to heredity, as are also vigor of body, attainments, and successes. 
Heredity and environment are two important determining factors 
in the Hfe of the child. Both exert their influence over the individual. 
I had been taught or in some way conceived the idea that the 
influence of heredity was predominant, but with the closest asso- 
ciation with developing children, coming into intimate relations 
with hundreds of them and watching carefully their physical and 
mental development, the great influence exerted by environment, 
which often means only opportunity, has been forced upon me, 
relegating heredity to the background. That certain diseases, such 
as syphilis and hemophilia, may be transmitted from parent to 
child is undisputed ; that certain physical states — the so-called con- 
stitutional vices — may also be transmitted, is indisputable; but 
that much of natural physical weakness and hereditary tenden- 
cies may be overcome by the beneficial influence of environment 
is now universally acknowledged. Heredity without favorable en- 
vironment counts for little. Given an ideal heredity for a child or 
one of the lower animals, place him under unfavorable conditions 
of environment and his favorable heritage counts for little. Feed- 
ing, care, and general good management shape his physical future 
much more than does inheritance. In proof of supposed inherited 
mental traits, the offspring of criminals or drunkards are pointed out 
as showing how they follow in the footsteps of their fathers and 
mothers. It must be admitted that here the hereditary influence 
is bad, but one should remember that their environment has also 
been very unfavorable. 

Mental traits much more than physical are apt to have an in- 
fluence on the future, and here again brilliant fathers rarely transmit 
their higher mental powers to their offspring, as is proved again 
and again in the professional and business world. Many of the ills 
laid at the door of heredity are due to errors in early management. 
In the breeding of animals great stress is laid upon pedigree, and 
credit is given accordingly. It should be remembered, however, 
that the stock-raiser appreciates the value of the young of his herds, 
and they invariably get the care that is best calculated to develop 
the perfect animal, which is exactly what the majority of the children 
of the human family do not get. A well-bred animal treated as 
many children from its birth to maturity would cut a sorry figure 
in the animal world. 

453 



454 HKRKDITY AND ENVIRONMENT 



HABITS 

Children readily acquire habits, good or bad. Under the man- 
agement of an intelligent attendant, directed by the physician, 
this natural tendency toward the repetition of an act may be turned 
to the child's inestimable advantage. There should be established 
in earliest infancy the habit of taking the nourishment at definite 
periods, and as the child increases in age, proper habits of sleep 
and rest must also be acquired. The child, too, should be bathed 
at a stated time and aired at a stated time each day, and, in general, 
in order to fulfil the requirements of vigorous animal life, his life 
should conform to a routine in which there is but little variation. 
Our sole object being the production of a good adult, only those 
habits tending toward proper growth and development should be 
encouraged. The habit of self-entertainment is an important one. 
An infant who requires to be constantly in arms when awake means 
a tired attendant, and usually a tired and irritable child. 

Bad Habits and Their Correction. — Among the bad habits early 
acquired and difficult to break, is that of thumb-sucking or finger- 
sucking and the use of the ** pacifier." The penalty paid by these 
children for such indulgence is thickened, boggy lips due to hyper- 
trophy of the orbicularis oris muscle and adjacent structures. Per- 
sistent sucking also produces a forward projection of the upper 
incisor teeth and an angular deformity of the upper jaw, and to my 
mind it is one of the very frequent causes of adenoids. At least the 
angular deformity or high-arched palate results in a marked com- 
promise of the nasopharyngeal space, so that very little adenoid 
tissue produces marked symptoms of obstruction. The cor- 
rection of the rubber-nipple and pacifier habit is readily accom- 
plished by the immediate withdrawal of these articles. The child 
will experience several fretful days and make it unpleasant for those 
about him, The thumb-sucking habit may be corrected by having 
the child wear a mitten or glove made of muslin or old linen which 
is shirred and tied at the wrists. Applying bitter drugs to the fingers 
or thumb is usually effective in controlling the habit. The tincture 
of aloes or a solution of the bisulphate of quinin, one dram to two 
ounces of water, is generally used, the finger being repeatedly moist- 
ened with the solution. Mothers will sometimes tell us with con- 
siderable amusement that the application of the bitter drug to the 
finger makes no difference to the child, who appears to like the taste 
of quinin or aloes. The child, however, soon tires of the bitter taste, 
and its continued use will always stop the habit. Biting the finger- 
nails may likewise be remedied by the use of these bitter solutions. 

The most pernicious habit, masturbation, is referred to on page 455. 

It is surprising in how many ways children will develop habits 
of manipulating different parts of the body. One of my most 
troublesome cases was in a child one year old who came to me with 



MASTURBATION 455 

an ear stretched to twice its normal size. During the greater part of 
its waking hours the child grasped and pulled at the top of the left ear. 

Another case was in a patient who was brought because of the 
habit of burrowing the right thumb into the right nostril. The 
nostril had become stretched to at least three times its normal 
size, causing a most peculiar deformity. 

It is impossible to make other than general suggestions for the 
correction of bad habits in children. When there is manipula- 
tion of the mouth, the sense of taste can usually be made to aid 
us. In other instances restrictions of a mechanical nature may 
be necessary. In the ear-pulling case, a tight-fitting muslin cap 
was worn constantly and the right hand kept pinned to the clothing. 
Punishment, rewards, and ridicule, all may be effectively used in 
the treatment of these cases. Regarding bad habits as to hours 
for feeding and sleeping, as well as the habit of carrying a child 
in arms — all may be corrected by doing the right thing at the right 
time and having a sufficient amount of courage to persist in it. It 
is to be remembered that, regardless of its age, a child is never 
harmed by rigid discipline properly applied. 

MASTURBATION 

Before the fifth year a great many more cases of masturbation 
are seen among girls than among boys. After that age it is more 
frequent in boys. The most common means of practising mastur- 
bation in either sex in infancy is by leg-rubbing. Contact by means 
of the edge of a chair or the corner of a sofa or any object against 
which pressure may be exerted is not infrequently the means 
used in older girls. Manipulation of the parts, while only occa- 
sionally seen in girls, is the usual method in boys after the third 
year. My youngest case was in a female child six months of age 
who was a "leg- rubber," and who evidently passed through a com- 
plete orgasm. In many the habit will be indulged in several times 
a day. 

In boys the primary causes of the practice, other than that of a 
neurotic habit, are an elongated foreskin, adherent prepuce, and phi- 
mosis. The handling of the parts necessary to keep the uncircum- 
cised clean is an exciting factor. In girls, vulvitis and vaginitis, 
with their resulting irritations, which are not relieved by cleansing 
and keeping the parts dry, are frequent causes. It is a popular 
notion that thread-worms may be an exciting factor; but among 
many cases of masturbation and many cases of thread-worms I have 
never seen both in the same child. 

Prophylaxis. — Masturbation is much easier to prevent than cure. 
In boys, prevention lies in having a clean, free glans, which in the 
great majority of male infants can be obtained only after proper sur- 
gical procedures. The elongated, thickened, uncut portion of the 
foreskin usually seen below the glans after a ritual circumcision is 



456 



HEREDITY AND ENVIRONMENT 



but little better than a free, elongated prepuce. The slitting of the 
foreskin which is sometimes produced by the so-called dorsal slit 
gives results very similar in character to a long, redundant foreskin. 
In girls, prevention in a certain degree rests in keeping the parts 
clean through washing them once a day with great gentleness, and 
the free use of non-irritating absorbent powders. A powder com- 
posed of equal parts of powdered starch and oxid of zinc gives very 
satisfactory results. 

With the habit of masturbation once estabHshed, the first step 
is to eliminate the cause, if it can be discovered, and put the parts 
in a normal condition. Circumcision in boys, releasing the adhesions 
to the cHtoris in girls, with cleanliness and as little manipulation 
as possible, are absolutely essential. 

The urine should be examined, and if found highly acid, it should 
be corrected by diet and by the use of bicarbonate of soda, from 
six to twelve grains being given daily, according to the age of the 
patient. If red meat has formed a considerable part of the diet, 



i^ 



'\ 



i 





Fig. 57. — Knee-crutch. 



the quantity should be reduced and given not oftener than three 
times a week. 

Having removed all possible sources of local irritation, we are 
in a position to use restrictive measures, as it is through such treat- 
ment only that a cure will finally be effected. If the practice is 
prevented the habit will soon be forgotten. The older the child, 
the more difficult will be the cure. The restrictive measures em- 
ployed depend to a considerable extent upon the age, sex, and 
method of practice. In young children of both sexes who practise 
leg-rubbing, a large napkin of some coarse material, or a towel, 
is placed over the napkin usually worn, and appHed in the same 
way, so as to keep the legs widely separated. After the napkin 
age a large towel may also be used, if necessary, for the same pur- 
pose, or the knee-crutch^ (Fig. 57) may be employed. Some children 
will indulge only when in a certain chair or in a certain position. 
iMade for the author by Geo. Krmold Co., 201 East 23d St., New York City. 



MASTURBATION 



457 



Illustrative Cases. — A very troublesome case in a girl seventeen 
months old was treated without success for several weeks, when I 
discovered that the child practised the act only when in her high 
chair, as by leaning forward and grasping the projecting arms she 
managed to bring the necessary pressure to bear upon the genitals. 
The use of the chair being discontinued, there was no further trouble. 

Another child, a girl six years of age, was an inveterate mastur- 
bator. She had been treated by several physicians. The act was 
repeated daily, sometimes two or three times a day, usually by con- 
tact, such as by pressure against the corner of a table, sofa, or chair. 




Fig. 58.— Brace Used to Prevent ^Manual Masturbation.i 



When in bed, she indulged in the practice by manipulation. She had 
become pale, thin, and hysterical, and being a member of a promi- 
nent family, great concern was felt for her. It seemed that here 
was a case where eternal vigilance was the price of safety. The 
external genitals were congested and swollen as a result of the 
direct irritation, otherwise they were normal. The gravity of the 
condition was apparent, and the parents readily agreed to my sug- 
gestion that the child should never be left alone. The mother 
and the nursery maid took turns in being with the child in the 
daytime. A trusty middle-aged woman was selected for the night 
1 Made for the author by Geo. Ermold Co., 201 East 23d St., New York City. 



458 HEREDITY AND ENVIRONMENT 

watch. I directed that no reference be made to the habit, but that 
the child should be severely punished if the practice was attempted. 
This, however, was not needed. This child, as is the case with all 
older children, masturbated in secret, and as she was never left 
alone the practice was stopped. She was given suitable food, 
teaching by a visiting governess was begun, and hard play was 
soon advised, as her physical improvement was rapid. As there 
was no further tendency to masturbate, the night watch was relieved 
after six months. The child was kept under the closest observation, 
however, for a much longer time. Cooperation to such a degree 
as in this family can, however, rarely be secured. 

Older children who practise manipulation of the parts can usually 
be watched during the daytime, but the habit is apt to be indulged 
in on going to bed, after the lights are out, and in the early morning, 
particularly when it is prevented during the day. In such instances, 
I have been obliged to advise mechanical restraint. An inexpensive 
and effective means is to use a piece of tape, which is tied in the 
center around the child's neck in a fiat knot, leaving the two ends 
long enough to be securely tied around the child's wrists, so as to 
allow a free movement of the hands above the umbilicus. The 
child can use the handkerchief, and adjust the bed-clothing, but 
cannot touch the genitals. If the patient is a girl and a mastur- 
bator by contact with any object, or a leg-rubber, a large bath-towel, 
if worn like an infant's napkin, will aid materially in discouraging 
the practice. A brace (Fig. 58), constructed of steel, with a hinge- 
joint to allow the arm to be extended to an angle of about 45 de- 
grees, has been used with success in a few cases. This brace is worn 
only at night. 



CONSTITUTIONAL DISORDERS 

ICTERUS— OBSTRUCTIVE JAUNDICE 

Jaundice of this type in children is usually associated with 
duodenitis and is caused by a swelling of the lymphoid bodies in the 
mucous membrane of the common bile-duct at its terminal opening 
into the intestine, and is due probably to the same form of infection 
that caused the duodenitis. I have seen but one case in which the 
jaundice was due to cholelithiasis — that of a girl six years of age. 
The patient had distinct attacks of biliary colic, with passage of 
gall-stones, and followed by intense jaundice. She was operated 
upon later and many stones removed from the gall-bladder. 

The onset of my cases has been almost invariably without high 
temperature, or the evidence of severe gastric disturbance. Usually 
the first sign that something is wrong with the child is a loss of 
appetite, a degree or two of temperature, a coated tongue, and 
listlessness. The yellow discoloration of the conjunctivae and the 
skin soon appears, which with the high-colored urine and slightly 
colored or grayish stools makes the case complete. 

Treatment. — Diet. — The reason why gastric disorders are consid- 
ered so prominent a symptom by many writers is possibly because 
of the gastric disturbance produced by their treatment. We are 
advised to place the patient on a milk diet and give calomel. I 
know of no treatment better calculated to produce vomiting and in- 
crease both the intestinal infection and the jaundice. The treat- 
ment which I have found most satisfactory is the use of very little 
food for twenty-four hours. Water is given as a drink and chicken 
or mutton broth well salted may be given with toast later if the 
child asks for food. He should not be urged to eat. The following 
day, broths, gruels, and orange-juice, with stewed fruits or lemonade, 
are given if the child wants them. 

Drugs. — The only medication used consists of rhubarb and soda. 
To a child five years of age I give four grains of pulverized rhubarb 
and eight grains of bicarbonate of soda from two to three times daily, 
giving at the same time considerable water. For a day or two suffi- 
cient should be given to produce a free laxative effect, but not neces- 
sarily to purge the patient. Usually on the third da^^ I begin with 
tincture of nux vomica and dilute hydrochloric acid — from two to 
four drops of each, well diluted. With the return of the stools to 
the normal the usual diet may be resumed, milk not being given 
for a week afterward. Rhubarb and soda are best given as follows : 

459 



460 CONSTlTUTlONAIv DISORDERS 

I^. Pulveris rhei gr. xlviij 

Sodii bicarbonatis gr. xcvj 

Syrupi rhei aromaticae § j 

Aquae q. s. ad ^ij 

M. Sig. — Shake well. Give one teaspoonful two or three times 
daily after meals. 

OBESITY 

Exceedingly fat children will usually be found to be large eaters 
and of inactive habits. It is rarely a serious condition and ordi- 
narily requires little more than certain restrictions in diet and 
regularity in exercise. Generally this is not difficult to obtain, as 
the patient is usually very anxious to reduce the weight because 
of the attention he attracts and the remarks the condition occasions 
in public places and among school-fellows. 

Treatment. — Diet. — In such cases I direct that all fatty foods, 
including butter and milk, be excluded from the diet. Skimmed 
milk may be given in moderation — not over one pint daily. It may 
be used on the cereal, and eight ounces may be given as a drink if 
the child is fond of it. The use of sugar, including candy and sweets 
of all kinds, is forbidden. Saccharin dissolved in the milk is used on 
the cereal and in making stewed fruits and plain puddings palatable. 

Exercise. — During the warmer months, golf, swimming, tennis, 
horseback exercise, and the bicycle are advised, a definite time, 
in hours, being prescribed each day for some active physical exercise. 
During the cold months, roller-skating, ice-skating, horseback-riding, 
out of doors when possible and indoors on inclement days, when the 
means are at hand, together with long walks, are a part of the daily 
life. A schedule is prescribed and written out for each day, depend- 
ing somewhat upon the station in Hfe of the patient, not only as 
regards food but also as regards outdoor exercise. In this way, by 
establishing a system of living covering the entire day, there will 
result, if the family cooperate, a reduction of the obesity with a 
marked improvement in the patient's general condition. 

Drugs. — The use of thyroid extract and other drugs for the reduc- 
tion of weight in children is not to be advised. 

During the treatment the child should be weighed regularly, as 
too pronounced results are not desired. 

THE ANEMIAS OF INFANCY AND CHILDHOOD 

A description of the treatment of the various forms of anemia 
as seen in the young, would be a repetition to a considerable extent 
of the management of malnutrition. Every child with anemia 
suffers to a certain degree from malnutrition also. The etiology 
of practically all the severer blood diseases in children, such as chlo- 
rosis, leukemia, the pseudoleukemic anemia of Van Jaksch, and perni- 
cious anemia, is but little understood. 

Treatment. — Cases of secondary anemia must be treated along 



THE ANEMIAS OF INFANCY AND CHILDHOOD 46 1 

symptomatic lines. Disordered intestinal digestion with its result- 
ing toxemias and systemic poisoning, which are also little under- 
stood, doubtless plays a major role in the blood diseases. The 
management of anemia in the young resolves itself into a cor- 
rection of existing digestive errors. The bottle-fed baby suffering 
from a grave form of anemia is given a better chance for recovery 
if he is placed on the breast. A wet-nurse should always be se- 
cured, if possible. When this is not possible the child's food should so 
be arranged as best to fit his digestive capacity, remembering that 
as high a proteid as is compatible with digestion should be given. 
These children also require all the advantages furnished by bathing 
and fresh air. An indoor airing (page 37) for hours at a time 
should always be given these children when they cannot be sent 
out of doors. The sleeping apartment should always communicate 
with the open air. If the patient is of school-age, the time when 
we see most of the secondary anemias, he should be allowed to attend 
only the morning session and be forced to rest for an hour or two 
after the midday meal. While exercise and play are necessary, 
they should not be allowed to the point of fatigue. More clothing 
will be required, both in winter and summer, than is needed for well 
children of the same age in the same climate. Among my dispensary 
patients I see a goodly number of these cases. I insist that the child 
shall occupy the sleeping- room alone and direct that the Hving- 
room or "parlor room," as it is sometimes called by these people, 
be used as the sleeping-room of the patient. If the parents are suffi- 
ciently well-to-do to send the child to the country, this is advised. 

As with all forms of malnutrition in children, the diet, when 
there is an associated anemia, is most important. A high-proteid 
diet should be given; red meat at least once a day, poultry, fish, 
eggs, milk, and butter; oatmeal, cracked wheat (each cooked three 
hours), together with the legumes and potatoes, should form the basis 
of the dietary. Better results, I find, are obtained by selecting foods 
that are rich in iron than when inorganic iron is given as medicine. 

The following table of Bunge may be of assistance in the selection 
of food for anemic children. It gives the number of milligrams of 
iron in the dried substances : 

Corn 1.0-2.0 Peas 6.2-6.6 

Wheat flour 1.6 Black Cherry 7.2 

Bovine milk 2.3 White beans 8.3 

Human milk 2.3-3.1 Carrots 8.6 

Figs 3.7 Strawberries 9.3 

Raspberries 3.9 Lentils 9.5 

Hazelnuts 4.3 Red Cherries 10.0 

Barley 4.5 Apples 13.0 

Almond 4.9 Beef 17.0 

Rye 4.9 Asparagus 20.0 

Wheat 5.5 Yolk of egg 10.0-24.0 

Buckwheat 5.7 Spinach 33.0-39.0 

Potato 6.4 



462 CONSTlTUTlONAIv DISORDERS 

It will be seen from the foregoing that the diet of many "run- 
about " children, viz., milk and the products of wheat flour, such 
as white bread, crackers, and cake, are substances comparatively 
poor in iron, and this doubtless helps to explain many of the anemias 
found at this age among the poorer classes. 

Iron. — In a great majority of instances in which iron is given 
to children it is used indiscriminately, in too large doses, and usu- 
ally without benefit. It is doubtless prescribed, on general princi- 
ples, more frequently than any other drug. I am yet to be convinced 
that it possesses any great value in the blood disorders in children 
other than chlorosis. Of this I am certain : when it is given without 
suitable attention to nutrition, digestion, bowel function, and general 
hygiene, iron is of no benefit, and is more frequently harmful, because 
it is very apt to increase the defective intestinal elimination, a con- 
dition usually present in anemia. The blood of the average child 
three years of age contains at the most only about six grains of iron. 
The advantage of prescribing three or four grains daily for a child 
of this age should hardly be considered. My results in secondary 
anemia have usually been satisfactory without iron when the pre- 
scribed diet and hygienic regulations were carried out. Iron is 
useful, however, in selected cases of anemia and of considerable 
service in chlorosis. 

In the selection of preparations of iron, those which are least 
irritating to the stomach, and the least constipating, should be 
chosen. With this in view, the citrates should be selected if the 
drug is to be given in liquid form. They are soluble in water 
and produce less digestive disturbance than do the other forms. 
The citrate of iron and ammonia and the citrate of iron and quinin, 
particularly the latter, have been found satisfactory. The dosage 
for a child two years of age or older is one grain, which is best given 
in sherry wine after meals. Where a patient can swallow a pill or 
a capsule, the extractum ferri pomatum in doses of from J to ^ grain, 
three times daily, alone or combined with nux vomica or quinin, 
will benefit the patient as much as iron is capable of. If the anemia 
and malnutrition are due to a remote congenital syphilitic infection 
(page 412), bichlorid of mercury in small doses — -^-^ to -^-^ grain, 
three times daily — is often productive of marvelous results. To 
my young patients suffering from malnutrition, particularly those 
in whom I am not Certain of the family history, I often give mercury 
in order to make a diagnosis more certain. 

Chlorosis occurs in young girls about the time of puberty or 
later. It is a disease in which drugs are given with most satis- 
factory results. Here iron and arsenic do good service, although 
I have seen cases which showed no improvement under medication 
make complete recoveries after a change of food and place of residence 
from the city to the country. Among the various lines of medica- 



RACHITIS 463 

tion I have found the following combination the most service- 
able: 

I^. Tinctiirae nucis vomicae gtt. cxx 

Extracti cascarae sagradae gr. x 

Extract! f erri pomati gr. xv 

Liquoris potassii arsenitis gtt. cxx 

Quininae bisulphatis oj 

M. div. et ft. capsulae No. xxx. 

Sig. — One after each meal. 

This is given for ten days, and repeated after five days' inter- 
mission. Interrupted medication is thus continued until recovery 
follows or until it is demonstrated that other drugs must be used. 
A patient with chlorosis should have all the advantages of diet and 
change of scene that the circumstances of the family will permit. 

RACHITIS 

Rachitis is a disease of nutrition, and is peculiar in that a greater 
part of the structures which make up the infant organism are in- 
volved in the rachitic processes. The bones show the character- 
istic deformities, the most common of which are the enlarged 
epiphyses, the square head, the open fontanel, the beaded ribs, and 
the lateral chest curves. The muscles are undeveloped and flabby, 
the mucous membranes are prone to catarrhal inflammations, and 
the nervous system shows a lack of development; rachitic children 
being particularly susceptible to disorders, such as laryngismus 
stridulus and infantile convulsions. Rachitic children are inva- 
riably anemic. Dentition is delayed, and when the teeth appear 
the}^ are apt to come in groups of four or more at one time and 
occasion no little disturbance. Repeatedly it happens that the 
first teeth are not cut until after the fifteenth month. Rachitic 
children are late in walking, suffer from constipation, and are usually 
below the average weight and size; in short, a child with rachitis 
is unique in the sense that he is constitutionally below the normal 
in every respect as regards growth, development, and resistance 
to untoward influences. The rachitic child is an easy mark for 
any disease which may be prevalent, and while rachitis itself is not 
a fatal disease, it contributes no small part to infant rnortality 
because of the low vitality which is characteristic of the condition. 
Bronchopneumonia, pertussis, and the gastro-enteric affections are 
all very dangerous in rachitic infants. Italians and the colored 
race are particularly susceptible to the disease. While well-marked 
rachitis is rare before the sixth month, infants two or three months 
of age show the beginning characteristic changes in the muscles and 
bones. 

Much has been written regarding the etiology of the disease in 
its relation to climate and unhygienic surroundings, and while 
such surroundings may contribute to the result, I have yet to be 



464 CONSTlTUTlONAIv DISORDERS 

convinced that as etiologic factors they are very important. It 
is true that we usually find rachitic children with unhygienic sur- 
roundings, but thousands of others who live under the same condi- 
tions do not have rachitis. A child fed on normal breast-milk 
will endure much that is not hygienic and still not develop 
rachitis. 

In the treatment of several thousand rachitic children, one fact 
has impressed me most strongly: Given a child suffering from 
rachitis, we have a child suffering from nutritional errors as a result 
of improper feeding, or an inability to assimilate a suitable food; 
and I have yet to see a case which did not improve when suitable 
nourishment could be given, and assimilated, regardless of the age 
of the patient. In children under one year of age the feeding of 
the proprietary foods or condensed milk is the most frequent cause 
of the disease. The next most frequent cause is the feeding of a 
too strong cow's-milk mixture, which produces indigestion and 
faulty assimilation. Breast-fed babies among the Italians and 
negroes occasionally have rachitis, and an examination of the breast- 
milk will invariably show a diminution of one or more of the nutri- 
tional elements — usually the proteid. 

A nursing woman in the New York Infant Asylum had such 
a free flow of milk that a foster-child was given her to nurse. The 
children failed to thrive; each made a gain of but two or three 
ounces weekly; both developed rachitis, one in a marked degree. 
Repeated examinations of the breast-milk showed it to contain 
1.5 percent fat, 4 percent sugar, and 0.5 percent proteid. 

After the first year fewer cases develop, but a late rachitis is 
by no means uncommon. In my own cases the development of 
the disease at this age and after, as in the very young, has been 
distinctly traceable to faulty feeding and faulty digestion. Not 
a few cases between the second and third years were considered 
due to prolonged nursing. I have known just two mothers who 
could nurse their children, and substantially nourish them, by 
the breast later than the twelfth month. Usually when the breast 
furnishes the only means of nourishment after the first year of life, 
a beginning rachitis will soon be noticed. The feeding after the first 
year of an exclusive diet of milk or of indigestible starches is not in- 
frequently a cause of rachitis. Among the poorer classes children 
during the second and third years are almost always badly fed. 
The diet usually consists of poor milk and poorly cooked starches. 
Children thus fed furnish no small part of our rachitic patients. 

Treatment. — It will readily be seen from the foregoing that the 
treatment of rachitis resolves itself into the adjustment of the diet 
to the needs of the patient. As growth and normal development 
cannot take place without proteid, and as the history of our cases 
has shown that this is the element which is most frequently lacking 



RACHITIS 465 

in the diet of rachitic children, the feeding of the proper amount of 
proteid should be our first consideration. 

The artificial foods and condensed milk are deficient in that in 
them both the fat and the proteid are low; therefore these foods 
should be discontinued and a properly adapted cow's milk substi- 
tuted. This appHes to children under one year of age. In a great 
many cases this is the only treatment required. 

Diet. — For those over one year of age, not only should the arti- 
ficial food be discontinued and cow's milk given, but the cow's milk 
should be supplemented by a diet rich in nitrogen. I order a diet 
composed largely of milk, scraped beef, soft-boiled ^gg, oatmeal, and 
wheat gruel. After the second year purees of beans and peas are 
added to the dietary because of the large percentage of proteid 
which they contain. It is impossible to prescribe a more definite 
dietary. The physician must remember that a diet as highly ni- 
trogenous as the child can assimilate is to be given. Unfortu- 
nately, many rachitic children cannot take cow's milk in quantities 
sufficient to make it of real nutritive value. This is often the result 
of an inability to digest the fat, the milk being taken without incon- 
venience when a large proportion of the fat is removed. Skimmed 
milk contains at least 3 percent of the chief nutritional element, the 
proteid, and makes a valuable addition to the diet. If a dilution of 
the milk is necessary, oatmeal gruel should be used. 

Many children who cannot take a full milk diet will take an 
ounce or two of butter daily without inconvenience. In older 
children I advise the free use of butter, one or two ounces daily. 
It is advisable to give rachitic children a moderate amount of fat, 
as it aids in the production of heat and thus saves the tissues. In 
children under one year of age cod-liver oil is often a valuable ad- 
dition to the dietary. In prescribing cod-liver oil I prefer to use 
the plain oil. In spite of the disgust adults have for cod-liver oil, 
children usually take it readily. The younger the child, the better 
the oil will be taken. For delicate children six months of age, 
from ten to thirty drops may be given three times daily after meals. 
From the sixth to the eighteenth month, from twenty drops to 
a dram may be given three times daily after feedings. After the 
eighteenth month from one to three drams may be given three 
times daily after meals. 

Hygiene. — Brine baths and oil inunctions aid materially in im- 
proving the child's condition as a whole, and are of great value. The 
brine bath (page 31), which is given at bedtime, is followed by an 
inunction of goose grease, unsalted lard, or cacao-butter. The goose 
oil or the lard is preferred. At least two teaspoonfuls should be 
rubbed into the skin. The benefit derived from the inunctions 
is largely due to the massage. The rubbing should be continued 
for at least ten minutes; the muscles of the back and legs should 
30 



466 CONSTITUTIONAL DISORDERS 

receive special attention. In a few children the animal fats act 
as irritants to the skin and produce a fine papular eruption. 

The rachitic child should have plenty of fresh air, by means 
either of a fire-place or an open window. On stormy and very cold 
days he should be given an indoor airing (page 37), being placed 
in his carriage or cart and wheeled about the room, and, to avoid 
drafts, the window or windows on only one side of the room should 
be opened. 

Rachitic children are very susceptible to head colds and bron- 
chitis; therefore every means must be employed to prevent ex- 
posure. As creeping and playing on the floor are the most frequent 
ways for a child's taking cold, the exercise pen (page 37) is par- 
ticularly useful in these cases. 

Drugs. — Drugs in my experience are of value only as they in- 
crease the appetite and the capacity for properly selected foods. 
The administration of phosphorus is without avail if the deficient diet 
is continued. Specific medication without proper food and a fair 
digestive capacity is valueless. With proper food and a fair digestive 
capacity, medication is superfluous, and a child rapidly recovers 
without it. 

Phosphorus I have used extensively and have yet to see a single 
case in which the beneficial action of the drug could be proved. 
In giving phosphorus, the oleum phosphoratum is the easiest and 
most convenient method of using it. One drop of the preparation 
represents y^^ grain of phosphorus. For children under one year 
of age, one drop may be given three times daily. For those between 
the first and second year, one and one-half to two drops may be 
given three times daily after meals. 

Deformities. — The deformities of the osseous system, particularly 
of the spine and the long bones, may be prevented — the first, by 
keeping the child on his back a greater part of the time, and if the 
deformity is well marked, by teaching him to sleep resting on his 
stomach. When kyphosis is present the child should be allowed to 
remain in the upright position but a few moments at a time. 

Deformities of the femur, tibia, and fibula occur long before 
the child attempts to stand, but too early use of the legs, while not 
necessarily a cause of deformity, may greatly aggravate the existing 
conditions. For this reason rachitic children should not be encour- 
aged to walk or stand until they have been under treatment for 
three or four months. 

Operative measures for the correction of bow-legs are better 
postponed until after the third year. If done at an earlier period 
the deformity is apt to return, and the late deformity may be greater 
than the original one. 

In my experience, the use of braces to correct the deformity of 
the legs has been of but little assistance, nor has any patient of 



SCORBUTUS. SPORADIC CRETINISM 467 

mine been benefited particularly when so treated by the ortho- 
pedic surgeon. The use of braces and jackets of plaster-of -Paris in 
kyphosis is usually unnecessary. Rest, massage, and exercises di- 
rected to restore power to the weakened muscles have answered 
well in my cases. 

SCORBUTUS— SCURVY 

Inasmuch as scurvy is a disease caused by improper feeding, 
the management is largely dietetic. Sterilized milk and the pro- 
prietary meal foods are responsible for a great majority of the cases. 

Treatment. — Dietetic. — The first step in the treatment is to supply 
fresh milk for the child, diluted, if necessary, to meet its digestive 
capacity. I have seen cases in which the diagnosis w^as made early 
completely recover under a change from sterilized milk to raw milk, 
without the aid of any other measure. Inasmuch as the disease is a 
most painful one, every means possible should be employed toward 
furnishing early rehef . Orange-juice is a specific for the disease. The 
child takes it greedily. One teaspoonf ul may be given at two-hour in- 
tervals, one ounce being given ordinarily in twent3^-four hours. Un- 
less the case is an advanced one, with extensive subperiosteal hem- 
orrhages and separation of the epiphyses, relief will be noticed in 
twenty-four hours and an entire cessation of symptoms in from 
five to seven days. I have seen a few cases entirely relieved at 
the end of seventy-two hours of treatment. These w^ere in infants, 
in whom the diagnosis was made very early — the only symptom 
being the evidence of pain during manipulation of the limbs in 
bathing or while changing the napkin; this is usually the first sign 
of the trouble. 

Illustrative Cases. — A case of long duration under treatment was 
in a boy eighteen months of age, who had been on almost an ex- 
clusive diet of a malted proprietary food from birth. The illness 
had existed for two months with extensive subperiosteal hemor- 
rhages and required three months of treatment before it could be 
considered well. In a comparatively recent case in my service at 
the Babies' Hospital, in which there was separation of the epiphyses 
of the humerus at the shoulder and of both femurs at the hip, three 
weeks were required to effect a cure. 

The management of more severe cases is the same as of those 
of milder type. Fresh food with orange-juice or beef-juice must 
be freety given. The patients should be handled very gently and 
only when necessary, as the pain on manipulation of the involved 
parts is most excruciating. 

• SPORADIC CRETINISM— INFANTILE MYXEDEMA 
Sporadic cretinism is due to an absence of, or to a derangement 
of function of the thyroid gland. In cretinism there is an arrest 
of mental and physical development, the latter being of a character- 



468 CONSTITUTIONAL DISORDERS 

istic type with retarded growth and developmental anomalies not 
seen in any other condition. Without treatment the cases which 
live through infancy become dwarfs and idiots. 

The Thyroid Treatment. — The specific treatment is the thyroid 
treatment. The most pronounced beneficial results of this treat- 
ment are noticed when it is brought into use early in life. The 
diagnosis of cretinism is rarely made before the fifth or sixth month, 
oftentimes much later, for the reason that the case does not happen 
to come under the observation of those competent to diagnose it. 

Illustrative Cases. — In two of my cases the patients were first 
seen by me, one at the fifth, the other at the seventh month. Other 
cases have been treated in institution and in private work; the 
two referred to, however, were seen earlier and almost daily for 
months, consequently there was an excellent opportunity for observ- 
ing the effects of the thyroid administration. A fairly complete 
history of one of the cases is as follows: The desiccated thyroid 
extract of Parke, Davis & Co. was used. At first it was given in 
one -half -grain doses twice daily. The beneficial effects were noticed 
in three days. The first change for the better was observed by 
the mother, who stated that the child seemed warmer and that less 
bed-clothing was necessary. The next positive change occurred, 
according to my records, on the fifth day of treatment. The child's 
general condition was very much improved. Her extremities were 
warmer, her color was better, and she commenced to move her 
arms; but what particularly impressed the mother was that less 
bed-clothing was needed to keep the child warm. At about the 
seventh day of treatment the patient cried vigorously when dis- 
turbed in changing the napkin, something which she had never 
done before. She had previously been stupid and apathetic. 
The next and rapidly following changes for the better, were that 
the patient noticed and appeared interested in her mother and 
followed her with her eyes about the room, and while previously 
she had rarely used her legs or arms except when disturbed, she 
now began to move them about voluntarily ; as the mother expressed 
it: ''The child had acted as though she were under the influence 
of some powerful depressant drug whose effects were gradually 
wearing off." When the child was five and one -half months old, 
after she had been under treatment for sixteen days, receiving 
one-half grain of thyroid twice daily, she smiled for the first time. 
She cut the first tooth at the ninth month and walked alone at the 
fourteenth month. She is now, at two years of age, taking three 
grains daily, and is apparently normal in every respect. 

Dosage. — The increase in the thyroid administration must be deter- 
mined by the condition of the patient. As long as progress is shown 
in more active and normal mentality, with an increase in the growth 
of the long bones and a gradual loss of the typical facial and other 



SPORADIC CRETINISM 



469 



characteristics, it is unwise to increase the dosage of the thyroid. 
When, however, a period arrives when no progress appears to be 
made, the daily dosage should gradually be increased by one-half 
grain. Evidences of overdosage are pallor, prostration, perspira- 
tion, and indigestion. When any of the above signs present them- 
selves, it is an indication to discontinue the medication for twenty- 
four hours and then resume with smaller doses. 

When the child in whom treatment was commenced at the 
seventh month was nine months of age, it was found necessary to 
give one-half grain three times daily. One month later, one-half 
grain was given four times daily. At this time the child could sit 
up and hold the head erect. The increase in the thyroid extract 
produced vomit- 
ing, and the dosage 
of one-half grain 
three times daily 
was resumed. One 
year after the com- 
mencement of the 
treatment, when the 
patient was nine- 
teen months old, 
two grains daily 
were required. 

In both of these 
infants the protru- 
sion of the tongue 
was one of the 
latest symptoms to 
disappear. 

My cases have 
varied considerably 
as to the amount of 

thyroid required. The dosage used was that taken by those in whom 
the disease was discovered very early in life. The older the patient 
when the thyroid is begun, the less marked the beneficial results. 

I have a little girl five years of age under treatment at the present 
time who came under my care two years ago, weighing fifteen pounds 
and three ounces. She made a marvelous improvement under 
one-half grain twice a day, which in two weeks was increased to one- 
half grain three times a day. This we were obliged to decrease 
because of the prostration and perspiration which it appeared to 
occasion. The dosage of one-half grain three times daily could not 
be used until she was four years of age. She is now five years 
old and requires one grain three times a day. In this child the 
most remarkable improvement was noted. (See Figs. 59 and 60.) 



j^^^H^^^^ '"'O*'^ 


K 




nl 


jK 'f! ■ 


1' 


W ^" 




'v 


^^; 



Fig. 59.— Cretin, before Treatment. 



470 CONSTITUTIONAL DISORDERS 

The interval of time between the photographs was thirty-four days. 
Six teeth were cut in three weeks after beginning the treatment and 
sixteen more were cut during the next six months. The child made 
corresponding improvement in every other respect. 

For another case, a nine-year-old girl, who is now normal in 
every respect except that her hair is rather coarse with a tendency 
to dryness of the scalp, it was found that the following amounts 
of desiccated thyroid were required at the various ages : 

Six months 1 i grains daily 

One year 3^ " " 

Two years 5 " " 

Three years 8 " " 

Four years 8 " " 



i^ 



/. 



This patient both walked and talked at fifteen months. In her 

case, in order to deter- 
mine what the effects of 
the withdrawal of the 
treatment might be, the 
thyroid was discontinued. 
■ This was first attempted 
when she was two and 
one-half years of age. 
V, ■> J The mother was asked 

l*^.. ^ j^y to keep close watch of 

her in order to detect 
the slightest difference 
in her behavior. After 
three days without thy- 
roid it was noticed that 
the child became less ac- 
. tive and disinclined to 

play. She was not irri- 
table or cross, but would 

Fig. 6o. — Cretin, after Thirty-four Days' Thyroid git in her little chair the 

Treatment. . r\i t i 

entire day. She had pre- 
viously been very bright, active, and talkative. A few days later 
she ceased to talk voluntarily and answered only when spoken to. 
After twelve days without thyroid it was resumed, and her activity 
again returned. About one year later a similar trial was attempted 
with similar results, although the duration of the test was shorter, as 
the mother, who was a dispensary patient and had had the thyroid 
furnished her, purchased a bottle of tablets and gave them on her 
own responsibihty. The child, now nine years old, is taking twelve 
grains daily. She is a normal, healthy school-girl, alive to all in- 
terests of girlhood, and no one in the village where she resides, out- 
side of the family circle, knows that she is a cretin. 



t 



STATUS LYMPHATICUS. PURPURA 47 1 



STATUS LYMPHATICUS 

Status lymphaticus is an unusual condition in which the lymph- 
atic tissue throughout the body is in a state of hyperplasia. 
The condition is usually associated with marked rachitic manifesta- 
tions. The chief interest attaching to the disease lies in the dan- 
ger of sudden death of those so affected and in the danger from 
the administration of an anesthetic, particularly chloroform. The 
lymphatic glands and the thymus are the parts particularly involved. 
Laryngismus stridulus and thymic asthma are frequent manifestations 
of the condition. It may exist, however, without the occurrence 
of either. The nature of the condition is not known. The cases 
which I have seen, a considerable number, were all sufferers from 
chronic intestinal indigestion. 

Illustrative Case. — In one case, a boy five months old — a 
most difficult feeding case — ^ there were from twenty to thirty 
attacks of laryngismus stridulus in twenty-four hours. Two 
trained nurses were in constant attendance. The entire duration 
of the seizures covered a period of two months. The marked fre- 
quency of the attacks continued for less than a week. The boy 
eventually recovered. When he was four years of age I removed 
both tonsils and adenoids under ether anesthesia without any 
unfavorable effects from the anesthetic. 

The most we can do with these patients is to improve their 
general condition along common-sense lines in relation to nutrition, 
rest, and exercise, as described in the section on The Delicate Child 
(page 148). Excitement and stress of any kind are to be avoided. 
In most instances the condition disappears under improved nutri- 
tion and a well-ordered life. 

PURPURA 

By purpura we understand that condition in which the blood, 
having escaped from its natural channels, becomes localized in dif- 
ferent portions of the skin and subcutaneous tissue with no constant 
change in the character of the blood or demonstrable lesion in the 
vascular wall. Purpura associated with scorbutus and peliosis 
rheumatica has been referred to elsewhere. Among the other forms 
met with, the difference appears to be largely one of degree, and 
is due to toxic conditions of various kinds. It may occur late in 
an exhaustive disease. Petechiae in the skin are frequently seen 
at the close of many of the exhaustive diseases, particularly in entero- 
colitis. Purpura may result from the administration of drugs. 

Illustrative Cases. — One of my patients two years of age devel- 
oped a mild purpura while taking large doses of antipyrin, which was 
being administered through a misunderstanding. In pyemia, pur- 
pura is not unusual. In a patient nineteen months of age, who died 



472 CONSTITUTIONAL DISORDERS 

from a septic sinus thrombosis with extension to the jugulars, there 
was extensive purpura for forty-eight hours before death. Blood ex- 
aminations of this patient during life showed pure cultures of strep- 
tococci. Another patient, a boy eight years of age, previously 
healthy, died in three days from purpura fulminans (Henoch). In 
this case also, blood cultures made post mortem, from subcutaneous 
hemorrhagic areas, showed pure streptococci. In the severe forms 
of purpura the hemorrhage is not confined to the skin, but occurs 
from the mucous surfaces or in the viscera. 

Treatment. — The treatment consists in establishing the vitality 
and resistance of the patient, in removing the cause when possible, 
and in the internal administration of acids and fruit-juices. The 
internal use of drugs, including the suprarenal extract and ergot, 
has not been of pronounced value in my cases. Calcium lactate 
in doses of two to five grains every three hours for children from 
tender age to puberty will be of more value than any other means 
of medication. In purpura fulminans the prognosis is necessarily 
very grave. When it develops in severe septic conditions or in 
prolonged exhausting diseases it is a symptom of much gravity. 
In these cases the free use of alcoholic stimulation should be resorted 
to early — one to two drams being given every two hours to a child 
five years of age. 

HEMOPHILIA 

HemophiHa is characterized by a tendency to uncontrollable 
bleeding following cuts and bruises. The cause of the condition 
has not yet been discovered. Various theories have been put 
forward from time to time. Heredity can be traced in most cases. 
Daughters of bleeders should not marry, as their offspring are likely 
to become bleeders, particularly the male offspring. 

Illustrative Case. — My personal experience deals with but one case, 
a boy who was under my care the greater part of his life. The fact 
that he was a bleeder was first suggested through hemorrhages into the 
skin about the knee and arm which appeared as soon as he com- 
menced to walk and to fall and bruise himself ; in fact, he was brought 
to my clinic at the Babies' Hospital Dispensary because, as the 
mother expressed it, he was continually black and blue. In all 
other respects the child was normal; in fact, he was an unusually 
strong, well-developed boy. Bleeding nearly caused his death 
at different times during the second, third, and fourth years. A 
slight cut in the skin meant days of bleeding. One particularly 
severe and prolonged hemorrhage occurred as the result of a fall 
when a tooth pierced the lip. Having the boy under observation 
for a long time and the assistance of an intelligent mother, we had 
an opportunity to test the various means of medication and other 
methods of treatment as suggested by different authors. Suffice 



HEMOPHILIA 473 

it to say that all measures, both general and local, were without 
the slightest benefit. The only means of controlling the hemor- 
rhage was by the use of strong pressure by means of pads and sur- 
geon's adhesive plaster. The pressure had to be exerted not only 
over the bleeding area, but for several inches above it. The child 
passed from my care when about five years old, but I learned that 
he died soon after from the operation of circumcision, which was 
necessitated by the sloughing and sepsis of the foreskin. 

The recent observations in the use of calcium lactate to prevent 
hemorrhage would suggest that there might be a field of usefulness 
for it in hemophilia. 



INFECTIOUS FEVERS 

INFLUENZA 

The management of influenza in a child is very similar to that 
of measles. The disease in itself is rarely of sufficient severity to 
cause any great concern. The possibility of serious complications, 
however, is great; the younger the child, the greater the danger. 

Treatment. — ^The disease is eminently contagious. Adults with 
influenza should not come in contact with younger members of the 
family. When one of a family of children is attacked, the child 
should be isolated as if he had measles or scarlet fever. The 
patient should be put on a reduced diet (see Diet in Illness, page 
139), and an initial dose of castor oil or one grain of calomel in 
divided doses should be administered. 

The temperature, which not infrequently reaches 104° F. or 
105° F., is usually readily controlled by sponging with alcohol and 
water, one part alcohol and two parts water, at a temperature of 
80° F. I have never been obliged to resort to the cool pack in 
grippe. This, of course, should be done if the temperature is not 
otherwise controlled. 

The pain, the muscle soreness, and the restlessness are very 
much alleviated by the use of phenacetin, caffein, and bicarbonate 
of soda, given in powders as follows, to a child one year of age: 

I^, Caffeinae citratis gr. ij 

Phenacetin .gr. v 

Sodii bicarbonatis gr. x 

M. Div. et ft. chart. No. x. 

Sig. — One every two hours— eight doses in twenty-four hours. 

In older children, those from two to four years of age, the following 
may be used: 

I^. Caffeinae citratis gr. iij 

Phenacetin gr. x 

Sodii bicarbonatis gr. xx 

M. Div. et ft. chart. No. x'. 

Sig. — One every two hours — not more than six doses in twenty-four 
hours. 

After the fourth year, I have found it of advantage to give the 
salicylate of soda instead of the bicarbonate. This, for a child 
from five to eight years of age, will be as follows: 

I^. Caffeinae citratis. gr. iij 

Phenacetin gr. xv 

Sodii sahcylatis gr. xxx 

M. Div. et ft. chart. No. x. 

Sig. — One powder every two hours — a maximum of six doses in 
twenty-four hours. 

474 



INFLUENZA 475 

The salicylate is best given in capsule form, as most children at 
this age may readily be taught to swallow a capsule. . 

So much for the medication of the uncomplicated grippe cases, 
the duration of which is usually from three to five days. Such 
cases occur in mild epidemics, in which the prominent symptoms 
are fever, loss of appetite, headache, prostration, and muscle sore- 
ness. 

Illustrative Cases. — Two fatal cases of grippe in infants, in which 
the diagnosis was made by exclusion and verified by autopsy, occurred 
at the Country Branch of the New York Infant Asylum, during the 
winter of 1888 and 1889, which, it will be remembered, was the time 
when grippe first visited this country in epidemic form. These 
healthy, breast-fed babies were taken with the disease together 
with about forty other inmates — mothers and children — in one 
of the larger wards. The infants in question, aged three and four 
months respectively, were stricken suddenly with high fever and 
marked prostration. They quickly went into a condition of col- 
lapse and both died in less than thirty-six hours from the onset. 
The autopsy failed to show any pathologic change other than a 
slight hypostatic congestion of the lungs. 

Complications. — ^The most frequent complication of grippe is bron- 
chitis, and the most fatal complication is bronchopneumonia. Sup- 
purative otitis is not an infrequent complication, or perhaps it would 
be better to class it as a grippe sequela. Among seventy-two cases 
of acute suppurative otitis, seen by me during the past two years, 
fifty-nine, or 81.9 percent, occurred with or followed immediately 
upon an attack of grippe. Patients who, after an attack of grippe, 
run a temperature without any apparent adequate cause, should 
always be examined by a skilled otologist. 

Occasionally grippe is ushered in with pronounced gastric dis- 
turbance. There will be nausea and vomiting, no food being retained 
for from twenty-four to forty-eight hours. Pronounced intestinal 
disturbance is by no means an unusual evidence of infection with 
the influenza bacillus ; there may be diarrhea without any evidence 
of involvement of the intestinal structure, or there may be a colitis 
with tenesmus and mucus and blood in the stools. In not a few 
cases the so-called complications are the only manifestations of the 
infection. This has led writers to describe a "grippe colitis," a 
"grippe gastritis," etc. I have seen two cases of endocarditis 
associated with grippe. 

Regardless of the way in which we interpret these various condi- 
tions, one thing is to be remembered, that when the influenza bacillus 
plays an important part in the infection, the successful management 
of a case is rendered more difficult as relates to the ultimate recovery 
from, and the duration of, the illness. After a severe so-called grippe 
colitis, grippe bronchitis or pneumonia, the patient is left in a debil- 



476 INFECTIOUS FEVKRS 

itated condition from which it may take weeks to recover. The 
quickest way to remove this indefinable "grippe spell" which 
rests over the patient is by a change of cHmate. Every late winter 
and early spring, I send a goodly number of children to Atlantic 
City. Two or three weeks there will do more to restore to health 
New York city patients than I am able to accomplish with drugs, 
baths, massage, and diet in an equal number of months at home. 
I have repeatedly seen children with tracheobronchitis with a nag- 
ging cough, which I had tried in vain to relieve, cease coughing 
within a very few days after reaching that resort. 

The management of an otitis, pneumonia, bronchitis, or colitis, 
associated with or following an attack of influenza, differs in no 
way, so far as the immediate treatment of the complication is con- 
cerned, from that which would be advised if the case were inde- 
pendent of the influenza bacillus. The case as a whole, however, 
will require closer watching, and on account of the greater prostration 
will need better feeding and freer stimulation. 

One attack of grippe confers no immunity upon the patient ; in 
fact, cases appear to reinfect themselves. For this reason, I always 
advise that two rooms be used, one for the day and one for the 
night, the room not occupied during the day being aired for several 
hours with all the windows open. After recovery, the sick-rooms 
should be thoroughly aired, cleaned, and fumigated with sulphur or 
chlorin gas. 

MALARIA 

The presence of the Plasmodium malaria in the blood in children 
should always be demonstrated before making a diagnosis of malaria, 
as in this way only can it be definitely determined that malaria 
exists. Aside from the periodicity in the temperature rise, there 
will usually be found in malaria an enlargement of the spleen; but 
beyond this the symptoms are vague and indefinite. The diagnosis 
of malaria is often made, and children are given quinin when the 
condition does not exist. According to my observation, a periodic 
rise in temperature which does not respond to quinin in full doses 
is not uncomplicated malaria. There are very few exceptions to 
this rule. 

Children are very susceptible to fevers of a periodic type. Per- 
sistent intestinal infection, otitis, encapsulated pus in the pleural 
cavity, grippe infections, fatigue due to over-indulgence in play — 
any one of these conditions may give rise to an elevation of temper- 
ature more or less periodic in type, covering a considerable period. 

Quinin Administration.— When it is demonstrated that malaria 
exists, quinin should be given in what might be considered large 
doses, if we are to use the adult for comparison. Children tolerate 
quinin well; in fact, to be effective, a much larger amount compar- 
atively is required than in adults. In giving quinin to young chil- 
dren, care must be used in its administration lest it excite vomit- 



MALARIA 477 

ing. For this reason it should be given after meals in solution or 
in capsule. The best menstruum is a preparation of yerba santa 
known as yerbazine.^ A child under eighteen months of age will 
require from eight to twelve grains daily. Two to three grains of 
the bisulphate should be given at a dose, not more than four doses 
being given in twenty-four hours. 

When resident physician at The New York Infant Asylum, then 
located in southern Westchester County, New York, there was a 
great deal of malaria among the women and children inmates. In 
that institution I have repeatedly given infants under four months 
of age eight grains in twenty-four hours. In some cases at this 
age a larger quantity — ten to twelve grains — will be required. 
Quinin chocolate tablets are sometimes used in giving the drug 
to children. In using these tablets it must be remembered that 
the quinin in them is in the form of the t annate, and that one grain 
of the tannate represents about one-third of a grain of the sulphate. 
In order to give sufficient quinin in this form to be of value, the 
large amount of chocolate in the tablet is sure to upset the digestion. 
In children under one year of age with whom yerberzine may dis- 
agree because of the sugar which it contains, the bisulphate may 
be given in solution in distilled water, followed by a teaspoonful 
of orange-juice. In older children — those from two to six years 
of age — from fifteen to thirty grains daily will be necessary to con- 
trol the disease. Here, as in the younger children, it is given in 
yerbazine unless the child can be taught to take a capsule, when 
it is given in three-grain doses at two-hour intervals imtil the pre- 
scribed daily amount has been taken. 

The giving of a large dose of quinin a few hours preceding the 
expected chill does not answer well in children, as a large amount 
given at one time is liable to cause vomiting. 

The use of quinin by inunction or by the rectum has not been 
satisfactory. Its use was so attempted at the Infant Asylum in 
a great many cases where difficulty was experienced in the stomach 
administration. 

In but one case, aged two years, have I been obliged to resort 
to hypodermic medication. The child showed the tertian parasite, 
and the disease resisted the internal use of quinin in large doses, 
but responded promptly to the muriate of quinin given hypoder- 
matically, seven grains being used at one injection. There was no 
abscess at the site of the injection and the child was permanently 
cured. To be sure, the administration of quinin was continued by 
the mouth, but the dosage of sixteen grains daily was now appar- 
ently effective where previously it had made no impression. 

Recurrence. — ^The use of quinin in malaria should not be stopped 
abruptly with a cessation of the fever. It is my custom to give it 
in full doses for one week after the temperature fails to rise, unless 
^ Made by Lilly and Co. 



478 INFECTIOUS FEVERS 

there is a subnormal temperature, in which event it is reduced one- 
half or temporarily discontinued. It is a difficult matter to determine 
when a case of malaria is cured. Time and again I have supposed 
that a patient was well when a recurrence of the paroxysms took 
place weeks afterward. How much of this was due to reinfection, 
and how much to the old infection which had not been entirely 
eradicated, is difficult to say. I am incHned to the belief, however, 
that in many instances the plasmodium had remained inactive 
in the spleen in spite of its return to nearly its normal size, for the 
reason that the recurrence of symptoms sometimes took place 
coincident with some other illness with fever, such as tonsillitis or 
acute indigestion. My experience with recurrences oi the disease 
has been such that after an attack of malaria I now direct that the 
child be given quinin for one week out of each month, for an indefinite 
time, at least for a year following the original attack. In a com- 
paratively recent case, a girl five years of age had repeated attacks 
for two years before coming under my care. The mother was 
instructed to give the child twelve grains of the bisulphate daily 
for seven days out of each month. This, without a change of resi- 
dence, was sufficient to prevent a recurrence during the fifteen 
months which followed. 

TYPHOID FEVER 

Typhoid fever is a rare disease in New York city children under 
two years of age. I have been able to prove but two cases in children 
under one year. One was ten, the other eight months of age. The 
diagnosis is often difficult because of the absence of the symptoms 
seen in the adult. The younger the child, the more likely is this 
to be the case. In neither of the above cases could we have been 
positive of typhoid without the aid of the Widal reaction. While 
usually the disease runs a shorter course in the child than in the 
adult, an attack means, at the least, several days of illness, and it 
may mean from three to six weeks. For this reason it is best to 
establish a sick-room regime, under which must be particularly 
considered the feeding, the bathing, the airing of the room, and 
absolute quiet for the patient. The bed-Hnen should be changed 
every day, and if the patient becomes very ill, but one attendant 
at a time should be in the sick-room. 

Bathing. — The typhoid patient should be sponged twice a day, 
an ordinary cleansing bath being given. During the bath, it is 
not necessary to uncover the patient. Parts of the body may be 
bathed and dried, when other parts may be given attention. 

Mouth Toilet. — Careful mouth toilet should be observed in typhoid 
fever in children. Gingivitis and ulcerative stomatitis with sec- 
ondary cervical lymph-node involvement are not infrequent com- 
plications of these cases. 

Care of the Discharges. — The discharges from both bladder 



TYPHOID FEVER 479 

and intestine should be received in vessels containing a i : looo 
solution of bichlorid of mercury. Carbolic acid should not be used. 
The necessity for the attendants to wash their hands with soap 
and water after attending to the patient should be made very 
plain. They should also be advised as to the proper disposal of 
the discharges. In children of tender age who still require the 
napkin, it is best to dispense with the usual article and use cheese- 
cloth instead, several thicknesses of which may be made of the 
required shape and burned when soiled. 

The Feeding of Typhoid Fever Cases. — Contrary to the general 
practice, I give little or no milk in typhoid cases. Early in my 
professional work I gave milk, which I had been taught was the 
only diet for the typhoid patient. I soon discovered that the less 
milk was given, the less the tympanites. I found that without 
milk the temperature ran lower, that there was less tendency to 
delirium, that the duration of the case was shorter and, as a whole, 
less severe. In fact, my observations bear out the teaching of 
Seibert, of New York, who was the first to advance the non-milk 
diet in typhoid fever. 

The diet which I now use consists largely of gruels made from 
cracked wheat, barley, rice, oatmeal, or any of the uncooked cereals 
by boiling for three hours one ounce of the cereal in one pint of water. 
At the completion of the boihng, boiled water is added to make 
the quantity of the gruel one pint. If the gruel is too thick for 
drinking, boiled water may be added. The gruel thus prepared is 
used as a "stock." It may be given plain, with salt or with sugar 
or both. I frequently add, as flavoring, two or three ounces of 
chicken or mutton broth. From six to eight ounces of the gruel are 
given every three hours — five to six feedings in the twenty-four 
hours. The patient is encouraged to drink water, which is given 
between feedings. Lemonade, tea, and weak coffee may also be 
given between the feedings. In the event of abdominal distention 
under the carbohydrate diet, the gruel is dextrinized by the addi- 
tion of "Cereo, "^ one teaspoonful to a pint of gruel. The gruel should 
be at a temperature of about 140° F. when the Cereo is added. 
Rice which has been cooked over night and then boiled for four 
hours is given once or twice daily. It is best to serv^e it with plenty 
of butter and sugar. 

When the temperature shows a tendency toward a lower level in 
or at the end of the third week, zwieback and toast are added to the 
diet. Later, when the tongue becomes clear and the breath loses 
its characteristic odor, kumyss, matzoon, skimmed milk, buttermilk, 
scraped rare beef, and soft-boiled eggs are allowed.* With the use 
of the more substantial foods, the number of feedings in the twenty- 
four hours is reduced to four. 

1 Cereo Co., Tappan, New York. 



48o INFEJCTIOUS FKVKRS 

Milk should not be given in any considerable amount before the 
temperature has been normal for one week. Even then, in a case 
which has had no milk or has had pronounced elevation of tempera- 
ture and intestinal disturbance, the giving of milk may cause a rise 
in the temperature. In not a few cases in which the temperature 
was running a low course — from ioo° to 102° F. — without tympanites 
or delirium, I have seen it shoot up to 105.5° ^', with furred tongue 
and distended abdomen, as a result of the administration of milk, 
which was usually given at the solicitation of friends, who feared the 
patient was being starved ! 

Illustrative Case. — A few years ago a girl, twelve years of age, 
had typhoid fever. The temperature was not high, the range being 
from 101° to 103° F. In fact, fever and an enlarged spleen were the 
only signs of the disease, until the diagnosis was confirmed by a 
positive Widal reaction. The tongue was moist throughout, as is not 
unusual when milk is not given. The family were fearful that 
the patient was not being sufficiently nourished. The mother 
had been told by a physician, a family friend, that such was the 
case. She begged that I allow the girl one glass, eight ounces, 
of full milk daily. I immediately ordered the nurse to give the 
patient one glass of Walker-Gordon milk once in twenty-four hours. 
She did so, and in three hours after the first glass the temperature 
had risen to 106° F., with abdominal pain and distention. One 
bottle of the citrate of magnesia and a high enema were given, after 
which the disease resumed its usual course on the previous diet, 
without milk, the temperature not going above 99° F. after the 
seventeenth day. An uneventful convalescence followed. 

Drugs. — With the so-called intestinal antiseptics in typhoid fever, 
my experience has been most unsatisfactory, so far as concerns their 
influence upon the disease. If there is constipation, the citrate of 
magnesia, from four to six ounces, given cold, is grateful to the 
patient and usually answers the purpose well. If the bowels do 
not move once in twenty-four hours, a high enema should be given. 
The digestive capacity is indicated by the condition of the tongue 
and may be improved by the use of dilute hydrochloric acid and 
the tincture of nux vomica. The following will be suitable for a 
child from five to ten years of age: 

I^. Tincturae nucis vomicae gtt. xlviij 

Acidi hydrochlorici diluti gtt. cxx 

Glycerin! o iss 

Aquae destillatae q. s. ad § iv 

M. Sig. — One teaspoonful after each meal. 

There may be as many as four bowel passages in twenty-four 
hours without harm to the patient. In fact, I consider from two 
to four necessary to maintain free drainage. When there are more 
than six in twenty-four hours, loose and watery in character, the 
loss of fluids sustained may be a serious factor in the case, in cans- 



TYPHOID FEVER 48 1 

ing a concentration of the blood, with a corresponding concentration 
of the poison, as shown in the marked general toxemia. 

Diarrhea in typhoid is best controlled by the use of opium com- 
bined with bismuth. For a child from three to five years of age, 
the following may be given : 

I^. Pulveris Doveri gr. x 

Bismuthi subnitratis gr. c 

(Squibb) 
M. Div. et ft. chart. No. x. 

Sig.— One every three hours until the stools diminish in frequency, 
when they may be given at intervals of from six to twelve 
hours. 

In children from one to three years old, the dose of the Dover's 
powder should be reduced one-half, the full amount of the bismuth 
being given. The amount required to keep the diarrhea under 
control will soon be learned. Of course, constipation must not be 
produced. If a free bowel action is interfered with, there will be 
increased prostration and higher temperature. 

Control of the Fever. — A temperature at or below 104° F. is not 
interfered with, in the great majority of cases. Of course, a very 
delicate child with a weakened heart action may require the use 
of antipyretic measures before this temperature is reached. This 
necessity, however, is unusual. My observation is that when above 
104° F. the patient does better if proper means are used to control 
the temperature. 

Antipyretic Drugs. — Antipyretic drugs are rarely given. Quinin 
in my cases has never proved to be of the slightest value, even 
when given in large doses — fifteen or twenty grains in twenty-four 
hours — to a child five years of age. The coal-tar products, such 
as phenacetin, may be used in small doses without harm, if hydro- 
therapy is not applicable, as in a case which I recently saw in a 
remote country district. The patient was a boy six years of age. 
He was delirious at times, with almost constant tossing about the 
bed, sleeping but little, with a temperature ranging from 105° to 
106° F. The disease was in the latter part of the second week and 
the patient was becoming rapidly exhausted. The parents, densely 
ignorant, refused to allow the bath or pack. The sponging, which 
was carried out indifferently, had not the slightest effect on the 
temperature and appeared to excite the patient. It was suggested 
to the attending physician that he give two grains of phenacetin 
and one -half grain of the citrate of caffein at intervals of from three 
to six hours. It was found that from four to six powders daily were 
required to keep the fever within the desired bounds and the skin 
moist. They had also a decidedly quieting effect upon the patient, 
whose heart action was in no way unfavorably influenced and who 
made a complete recovery. Had the great restlessness, the loss 
of sleep, and the delirium continued, I have no doubt but that 
there would have been a fatal termination. 
31 



482 INFECTIOUS FEVKRS 

While there is much truth in what has been written as to the 
depressing effects of the coal-tar products, and while the dangers 
from their excessive use are realized, there are occasions where they 
are a necessity, and I cannot help feeling that the dangers have 
been exaggerated. Probably the diseases in which their use is most 
dangerous are pneumonia and the inflammatory conditions of the 
heart. 

Hydrotherapy. — Pyrexia is best controlled by hydrotherapy. 
Sponging with lukewarm or cool water may be tried, and if the case 
is not a severe one, this may answer. The child may be sponged 
with water at from 70° to 80° F. for one-half hour out of every 
two or three hours. Sponging, however, even if it controls the 
temperature, may not be the best means of using water for this 
purpose, for the reason that many children object to it, and in con- 
sequence the sponging disturbs them, increasing their irritability 
and reducing their vitality. The use of the bath for the reduction 
of fever in children I have discontinued. They invariably object 
to it, the bath excites or frightens them, and, as a rule, particularly 
in the very young and delicate, the reaction following it is poor. 
Moreover, the bath necessitates a great deal of handling, undressing 
and dressing, and therefore tires the patient. Reduction of the 
temperature by means of a rectal irrigation with cool water has its 
advocates. If the temperature is running high and intestinal 
lavage is indicated for reasons other than the temperature, it may 
be used here, the water being of a lower temperature than that of 
the body, though I never use it lower than 80° F. for this purpose. 
Without a high body- temperature, however, and other indications 
as well, it is never to be used. It causes straining, excites the child, 
and thus increases the danger of hemorrhage and perforation. 
Furthermore, it is a very indifferent antipyretic, even when used 
with water as cold as 75° F. By far the best means of reducing 
the temperature in children is the use of the cool pack (page 503). 
Its advantages are that it causes no fright or shock, the child being 
disturbed comparatively little by it. He may be placed in a towel, 
which has been wet with water at 95° F., and the only manipulation 
necessary is to turn him from side to side, so that the towel may 
be kept constantly wet with the cool water at the desired temperature. 
The pack more effectually controls the temperature than does either 
sponging or the tub-bath, and it is thus kept within the desired 
limits. As suggested elsewhere (see page 285), the child should be 
removed from the pack when his temperature reaches 102° F. 

Heart Stimulants. — If the heart by the rapidity of its action shows 
signs of failure, the tincture of strophanthus is our best remedy. 
When there is irregularity in force and rhythm, strychnin should be 
used. A child from five to ten years of age may be given two drops 
of the tincture of strophanthus at intervals of from two to four hours. 
Strychnin, yJq- grain at intervals of from three to four hours, may be 



ERYSIPELAS 483 

given for the same age. Alcohol should not be given as a heart 
stimulant until other means have failed. It is a drug to be used 
only in conditions of great stress. Its function is to carry us over 
and out of difficult places, and it may be given in the form of 
whisky or brandy, one to three drams at intervals of from two to 
four hours in children from three to ten years of age. Its con- 
tinued administration for a considerable period is not to be ad- 
vised. In any disease it is difficult to lay down definite rules for the 
administration of heart stimulants. They are used with the hope 
of producing a definite effect, and when such effects are produced, a 
larger quantity should not be given. It is best always to begin 
with small doses and gradually increase until the desired results are 
apparent. 

Hemorrhage and Perforation. — Hemorrhage has not occurred 
in any of my cases which were given the non-milk diet. Should it 
occur, the cold coil or the ice-bag should be applied and Dover's 
powder given in full doses to control peristalsis. In case of per- 
foration, operative procedures are to be resorted to, but these hold 
out little hope. Children bear abdominal operations badly, and, 
considering the exhausted condition of a young child in the third 
or fourth week of a severe typhoid, the outlook is most unfavorable. 

ERYSIPELAS 

Erysipelas is a particularly fatal disease in infants. In the 
new-born, 95 percent of the cases are fatal. Fifty percent of my 
cases occurring in children under one year of age have been fatal. 
When the streptococcus of erysipelas gains entrance into the skin 
of an infant, it is unusual if the entire skin surface does not become 
involved before the process subsides. The long-continued high 
temperature, the toxemia, the discomfort from the inflammation, 
and the interference with nutrition greatly reduce the patient, and 
if he resists the disease during the acute stage he is very apt to die 
later from exhaustion. This was the outcome in four cases seen 
recently at the New York Infant Asylum, where each child went 
through the active period of the disease, but died a week or two 
afterward from exhaustion and marasmus. 

Treatment. — The treatment is unsatisfactory, particularly so in 
young children — the younger the child, the graver the prognosis — and 
absolutely nothing is to be promised. I have employed scarifications 
in advance of the line of the slowly creeping inflammation, and 
whether solutions of the bichlorid of mercury, carbolic acid, or 
ichthyol were used as a dressing, I have seen the red line pass the 
scarified disinfected surface regardless of the nature of the antiseptic 
and regardless of the vigor and vitality of the child. The termination 
of the cases, whether in recovery or death, depends to a great extent 
upon the resistance of the patient and the severity of the infection, 



484 iNi^KcTious fe:vers 

so that our first step should be to place the child in the best position 
to resist the disease. 

Hygiene. — One of the first, perhaps the most important factor 
in the treatment of these cases is abundance of fresh air. In 
the winter the child does best when placed in a room with windows 
wide open, not for a few moments but continuously. Protected with 
hot-water bags and sufficient clothing, there is no danger, as long 
as the temperature of the room does not fall below 55° F. At 
other seasons of the year the patients should, if possible, be kept 
out of doors. 

Infants with erysipelas are particularly liable to develop gastro- 
enteric disorders. In case the child is bottle-fed, the milk mixture 
should at once be reduced from 50 to 75 percent by the addition of 
barley-water or Granum-water, No. i, so that the amount of fluid 
given at a feeding remains unchanged. 

Internal medication such as I have used has been of no value aside 
from its stimulating or sustaining nature. The tincture of the muriate 
of iron is not to be given young infants with erysipelas. It almost 
invariably disturbs the appetite and interferes with the digestion. 

Local Applications. — ^The local measure which is unquestionably 
of some value is the use of ichthyol. I prefer a 10 percent solution, 
if the involved area is one or more of the extremities or a small por- 
tion of the trunk. Solutions as dressings should not be used in infants 
when the erysipelatous process involves the face or much of the 
trunk. When these parts are involved, a dressing of 30 percent 
ichthyol ointment in vaselin is applied on strips of lint or linen and 
renewed every three hours. The frequent renewal is important, and 
the ointment dressing should be used only on the acutely involved 
areas. When in a given case the inflammation begins to subside, the 
dressings should be removed and the parts bathed freely. It must 
be remembered in this connection that the skin is an important organ 
of excretion, particularly of carbon dioxid. The constant covering 
of comparatively large surfaces on a small child, interfering, as it 
does, with the function of the skin, may become a serious matter. 
The local treatment with ichthyol should follow up the extension 
of the inflammatory process and be continued until it subsides. 

Stimulants. — Nearly every infant with erysipelas will require stim- 
ulation. For this purpose small doses of whisky well diluted appear 
to answer best. From five to fifteen drops at two-hour intervals for 
children under two years of age have aided me, I am sure, in carry- 
ing the patient through to a successful convalescence. 

Erysipelas is the only disease in which it is wise to use alcohol as 
an early and oftentimes the only stimulant. When the inflammation 
subsides the child is by no means to be regarded as well. In the 
absence of sequelae, such as a phlegmon, an endocarditis, or nephritis, 
the vitality may have become so reduced that sudden death may 



RHEUMATISM 485 

take place when it is thought the patient is well on the road 
to recovery, such a result being due, perhaps, to an unrecognized 
myocarditis. During the entire attack and throughout convales- 
cence the child should be fed to the limit of his digestive capacity, 
never beyond it. This can be done only by careful observation of the 
case and frequent inspection of the stools. 

Vaccine Therapy. — The value of vaccine therapy in this disease 
remains to be proved (see page 530). 

In the event of high temperature, above 104° F., the cool pack 
(page 503) may be effectively used. 

RHEUMATISM 

Rheumatism is an exceedingly rare disease in children under 
two years of age. It is occasionally seen in those between the 
second and fourth years and is of very frequent occurrence after 
the fourth year. 

The manifestations of rheumatism in children are many. Prob- 
ably its most frequent manifestation is in the catarrhal inflamma- 
tory conditions of the respiratory tract and in indefinite muscle 
pains, commonly known as growing pains. Inflammatory conditions 
of the upper respiratory tract, particularly such as relate to the 
mucous membrane of the throat and the tonsils, in a majority 
of instances are due, probably, to a rheumatic infection. 

In children, involvement of the joints is also a result of rheumatic 
infection, but there is less tendency to joint involvement in them 
than in adults. 

During the past twelve months I have had four cases of pleurisy 
with effusion of rheumatic origin. 

Endocarditis is a frequent manifestation of rheumatism — a 
part of the disease and not a complication. Some of my most 
severe cases of endocarditis have shown the most trivial joint and 
muscle symptoms. In other cases there has been endocarditis 
without a single joint or muscle symptom. Usually those children 
of rheumatic inheritance whom we question closely, we shall find 
have had more than their share of tonsillitis and sore throat. It 
is the strong tendency to heart involvement in rheumatic children 
that should mark any child so affected as an object for special 
prophylactic care. 

Children with growing pains or with respirator}^ indications 
of rheumatism, such as repeated bronchitis and asthma, with or 
without a pronounced rheumatic history, should receive prompt 
treatment for the condition. For although we believe the acute 
inflammatory involvement of the heart and joints to be of bacterial 
origin, nevertheless, before infection takes place, there must be 
a favorable field for the development of the specific bacteria, if there 
are such, to operate in. The peculiar condition of the blood and 



486 INFECTIOUS FEVERS 

tissues, that something which favors a fertile field for the specific 
bacteria, may be the result of heredity or of errors in living, particu- 
larly as relates to the diet. In any event, proper feeding and appro- 
priate dietetic regulation will change this receptive state to one of 
apparent health. This is proved by the relief furnished to children 
who have suffered much from growing pains, and by a reduction of 
from 60 to 80 percent in the number of attacks during the year of 
inflammatory throat conditions. 

It will usually be found that rheumatic children combine one 
or two, or perhaps all, of the following conditions: They have a 
rheumatic inheritance, they habitually indulge to excess in sweets — 
by which I mean sugar in any form — and a considerable part of 
their daily food is red meat. 

Treatment. — Diet. — My first step in the management of a case of 
this nature is to eliminate red meat from the diet for ten days or 
two weeks. A minimum amount of sugar is given, just enough to 
make the food palatable. In a case which resists treatment, or when 
there is a rheumatic inheritance, saccharin is substituted for sugar. 
The child is encouraged to eat freely of green vegetables. The use 
of potatoes boiled with the skins on is encouraged. Fish, eggs, 
and poultry are allowed as usual. In order that the child may 
not suffer from the removal of a large amount of proteid from the 
diet, cereals and legumes rich in proteid are given. Particularly 
useful in this condition is plain oatmeal, which, of course, should 
be cooked three hours. Dried peas, beans, and lentils are given 
in the form of a puree. 

Drugs. — In addition to these changes in the diet, a child of 
from five to ten years of age is given ten grains of bicarbonate of 
soda, three hours after breakfast and dinner for one week, and 
five grains three hours after each meal for the second week, 
after which time he is given five grains of the bicarbonate of soda 
twice daily for five days, with a ten-day intermission, when the 
dosage is repeated. For six weeks the soda is used in this way — for 
five days with ten days' intermission. The low sugar and the low 
meat diet should be continued indefinitely if there is a rheumatic 
history, or if the child has had repeated rheumatic attacks, whether 
such manifestations have been in the throat, in the muscles, or in 
the joints. The mother should be instructed to resume the bicar- 
bonate of soda with the first complaint of pain on the part of the 
child. If the growing pains continue in spite of the diet and the 
bicarbonate of soda, five grains of the salicylate of soda should be 
given after each meal, the use of the bicarbonate being continued. 
It is not wise to continue the salicylate after the acute symptoms 
have subsided. 

Children who are subject to frequent attacks of rhinitis, tonsilHtis, 
and angina, with or without a rheumatic history, should indulge 



RHEUMATISM 487 

Sparingly in red meat, never more than once a day, better every 
second day. Only sufficient sugar to make the food palatable should 
be allowed. The use of candy should be reserved for very rare 
occasions. A warm bath should be given at night, followed by a 
generous friction of the skin in drying. 

Illustrative Case. — Asthmatic bronchitis is usually dependent 
upon the rheumatic state. Repeated attacks suggest the probability 
of their being of rheumatic origin. A Httle girl eight years old was 
brought to my office about a year ago, because of repeated attacks 
of bronchitis. The mother, a woman of unusual education and 
refinement, stated that the child had had an average of two attacks 
of bronchitis monthly during the previous year, and at least one 
every mionth since she was five years of age. On my expressing 
some doubt as to the frequency, she stoutly maintained that her 
statement was correct. The family lived in Brooklyn and had been 
told that the child could not remain there during any portion of the 
year. She had spent the colder months at different winter resorts, 
with very little, if any, resultant effect upon the severity or fre- 
quencv of the attacks. The child was pale and inclined to stoutness. 
There had been no other illness of consequence. The attacks were 
peculiar in that they were of short dura'tion but very severe. There 
usually was a temperature range from ioo° to ioi° F. There were 
cough and difficulty in breathing with occasional attacks of marked 
air hunger. The attacks were always accompanied by severe 
corvza. She came to me at the end of an attack. An examination 
of the chest show^ed throughout a fairly even distribution of mucous 
rales, involving the smaller tubes. Aside from the bronchitis and 
secondary anemia, the examination was negative. The child had 
attended school at irregular intervals, but only for a few weeks 
of her life. While getting the history, I asked, as a matter of routine, 
if the child snored or if she were a mouth-breather. This caused 
the mother to remark that the child had been under the care of 
throat specialists at different times and each of them had removed 
a set of tonsils and a set of adenoids ! She did not think that there 
was very much left. In spite of a normal rhinopharynx, the colds 
had continued. There was not a sign of a tonsil and the nasopharynx 
was free. In taking the family history, I had learned that it was 
rheumatic on both sides, extending back for two or three generations. 
The mother claimed to have suffered a great deal from rheumatism. 
In getting the personal history, I asked if the child was fond of red 
meat. The reply was that she lived on it, and cared for little else, 
unless it was sugar. Here was a girl eight years of age who would 
not drink milk until sugar had been added to it. Cereals, stewed 
and raw fruits were loaded down with sugar before she would touch 
them. 

In mv instructions as to the treatment, red meat was allowed 



488 INFECTIOUS FKVKRS 

once every second day and sugar was reduced to a minimuni — pro- 
bably not more than one-fifth the usual amount being given. She 
was to be bribed, if necessary, to eat green vegetables, cereals, and 
fruits. Expectorant and cough mixtures were discontinued. She 
was given twenty grains of the bicarbonate of soda and twenty 
grains of the salicylate of soda daily for three weeks. Later, the 
drug treatment was continued at intervals during the remainder 
of the winter. She passed through the following winter without 
a sign of rhinitis, bronchitis, or asthma, although she continued to 
live in Brooklyn. 

Another case somewhat similar was sent to me by a well-known 
rhinologist. The girl, seven years old, had suffered from repeated 
attacks of bronchitis and asthma. She had been confined to her 
home a greater part of each winter. Her general condition was 
thoroughly wretched. Her family physician attributed the con- 
dition to enlarged tonsils and adenoids. The child was sent to 
New York for operation. The operation was performed and the 
child returned to her home. As a result the patient could breathe 
easier and sleep better, and suffered much less during her attacks 
of asthmatic bronchitis; but the frequency of the attacks was in 
no way affected. Early the following summer, they returned to 
the rhinologist, who, finding the condition of the upper respiratory 
tract satisfactory, asked me to take charge of the case, remarking 
that he had "cut everything in sight and out of sight"! The child, 
as did the other referred to, proved to be an excessive meat and 
sugar eater, and, moreover, the mother's family was rheumatic. 
The treatment outlined above was instituted ; and, while the results 
were not so flattering, the condition was much improved; only 
three attacks occurred during the next twelve months, and the child 
gained fifteen pounds in weight. 

Repeated inflammatory involvement of the mucous membrane 
of the upper respiratory tract in children, in the absence of enlarged 
tonsils and adenoids, suggests strongly a rheumatic element as a 
prominent causative factor. Rheumatic pleurisy requires the 
same treatment as rheumatism. In my four cases referred to above 
there was a rheumatic history in two. The children were between 
two and six years of age. There was no pneumonia, no lung in- 
volvement of any nature. Aspiration showed clear fluid, which, 
upon examination, proved sterile. The children were given an 
anti-rheumatic diet with the sahcylate and the bicarbonate of soda 
in doses suitable for their ages, with the result that in all there was 
a complete absorption of the fluid in less than one week. The 
treatment of rheumatic endocarditis will be found elsewhere (page 

305). 

Treatment. — Diet. — Acute articular rheumatism or rheumatic 
fever is rarely seen in children under three years of age. It is usually 



RHEUMATISM 4^9 

the larger joints that are involved — the shoulder, the elbow, the knee, 
or the ankle. The lesion may be single or multiple. Rest in bed is 
an absolute necessity. The diet of the patient may consist of milk, 
junket, gruel, toast, stale bread, weak tea, stewed fruit, and orange- 
juice. Vichy and lemonade may be given to drink. There should 
be one evacuation of the bowels daily. 

Local Measures. — Considerable comfort may be furnished by 
local measures, which wih permit the child to sleep, resulting in 
a much improved food capacity. The affected joint or joints 
should be comfortably supported on a cushion or pillow, and 
the parts kept well protected by cotton-wool or flannel dressings. 
The U. S. P. lead and opium solution which is used to moisten the 
gauze dressings will aid in relieving the pain. The joint is loosely 
wrapped in strips of linen which have been wet with the warm 
solution. Over this is placed oiled silk to prevent rapid evaporation 
and over all a flannel bandage is wrapped. In the acute cases the 
dressing should be changed every hour until the pain is relieved. 
This can readily be done without disturbing the patient. A liniment 
composed of menthol, two drams, tincture of opium, one and one- 
half ounces, and enough alcohol to make six ounces, applied on 
strips of linen and covered with oiled silk, is another form of local 
treatment which has been of considerable service in relieving pain. 
The dressing should be renewed every two or three hours if the 
case requires it. 

Drugs. — ^Various drugs, such as oil of wintergreen, aspirin, and 
combinations of the alkalies with the salicylates, have been used 
in a considerable number of cases. The most effective internal 
medication has been the bicarbonate in association with the sali- 
cylate of soda. The salicylate must be given in large doses. Tw^o 
points, however, are to be kept in mind in the use of large doses 
of salicylate in children: Their depressing effect upon the heart, 
and their tendency to produce derangement of digestion, as evi- 
denced by nausea and vomiting. The salicylate should never be 
given with the stomach empty. It is given to the best advantage 
after meals, and always in solution. For a child five years of age, 
the following may be prescribed : 

I^. Sodii salicylatis 5ij 

Elixiris simplicis o^ss 

Aquse q. s. ad 5 iv 

Sig. — One teaspoonful four times daily after meals, in plain water 
or in Vichy. 

There are about twenty-four teaspoonfuls in a four-ounce bottle. 
The average teaspoonful, as is well known, holds more than one 
dram. Computing twenty-four doses to a four-ounce mixture, we 
give this five-year-old patient twenty grains of salicylate of soda 
in twenty-four hours. The amount may be increased to thirty 



490 INFECTIOUS I^EVKRS 

grains if the condition is serious. Larger doses than thirty grains 
to children of this age I do not consider safe, as I have seen such 
doses followed by irregularity of the heart's action and cyanosis. 
The average child from eight to ten years of age will take thirty 
grains daily without inconvenience. From the second to the third 
year, I have given from twelve to fifteen grains repeatedly, with 
most satisfactory results. The bicarbonate of soda may be given 
in combination with the salicylate, but it is best given alone in 
Vichy or carbonic water between meals. For a child five years 
old or under, twenty grains should be given in twenty-four hours. 
In children from seven to ten years of age, thirty to forty grains 
daily is the amount required. During an attack of rheumatic 
fever, the patient's heart should be examined daily. The dosage 
both of the salicylate and the bicarbonate of soda should gradu- 
ally be reduced, as the condition of the child improves. 

It is my custom never, willingly, to let a child who has once had 
an attack of acute articular rheumatism disappear from my observa- 
tion. With repeated attacks, endocarditis is liable to develop sooner 
or later. After one attack, the parents are advised as to the proba- 
bility of a recurrence, and its dangers are pointed out to them. They 
are instructed to keep the child on a low meat-and-sugar diet — red 
meat never being allowed oftener than once every second day, while 
sugar is given only in sufficient quantity to make the food palatable. 
Five days out of every fifteen, ten grains of the salicylate of soda, 
separately or combined with ten grains of the bicarbonate, are given 
daily. This should be continued for six months, when the five- 
day treatment out of each month will suffice. In some cases I 
have continued this method indefinitely. 

At the present time a boy eleven years old, who has had two 
attacks of rheumatic endocarditis, is taking ten grains of each of the 
above drugs daily for one week out of each month, and has been 
doing so for two years. He comes of a long line of rheumatic an- 
cestry, and so prominent is the rheumatic element in him, that he 
frequently has attacks of angina and muscle pain in spite of the diet 
and the above prophylactic treatment. 

PELIOSIS RHEUMATICA 
In this unusual affection, which appears to be of rheumatic 
origin, purpura is a prominent symptom. In my patients the pur- 
puric area has always been over the anterior portion of the lower 
extremities. My cases, five in number, have all occurred in those 
who had had previous attacks of rheumatism or chorea, or in those 
in whom the rheumatic element was prominent, as shown by re- 
current tonsilHtis or recurrent bronchitis. A further proof of the 
rheumatic origin of the disease is the fact that the cases usually 
yield readily to treatment for rheumatism. 



TUBERCULOUS PERITONITIS 491 

In one of my patients there were two distinct attacks, both of 
which yielded fairly well to the salicylate of soda and the iodid of 
potash. The medication and diet are the same as that suggested 
for rheumatism. In case erythema nodosum is present at the same 
time, local measures for the relief of pain (page 432) will be neces- 
sary. 

ACUTE GENERAL PERITONITIS 

This disease is not an infrequent one in young children. I 
have seen four cases during the past year. Two were associated 
with scarlet fever and two with enterocolitis. Perforation of the 
intestine and trauma may cause peritonitis, as in the adult. The 
most frequent cause, however, is the invasion of the peritoneum 
by pathogenic bacteria. The peritoneum in young children appears 
to be particularly susceptible to various forms of infection. Three 
symptoms were present in my cases — persistent vomiting, marked 
abdominal distention, and constipation. Pain was absent in one 
case and not marked in some of the others. The pulse in all was 
small and rapid. The constipation was as obstinate as though 
actual obstruction existed. 

The medical treatment in my experience has been without value. 
Every case has resulted fatally. In the majority, surgeons were 
called in consultation, but invariably advised against operative 
procedures. 

Never having had a case recover, I am not in a position to advise 
treatment. 

Illustrative Case. — A strong vigorous girl, three years of age, 
developed a moderately severe entero-colitis. Response to treat- 
ment was fairly prompt, and in ten days the child was convalescent. 
Suddenly there was marked distention of the abdomen, persistent 
vomiting, and obstinate constipation. These S3^mptoms, with grad- 
ually increasing prostration, continued for three days, until the 
child died. The autopsy showed an acute general streptococcic 
peritonitis. Streptococcus was found in the enlarged mesenteric 
glands, proving that the intestinal tract was the source of the infec- 
tion. 

In another case, an infant of six months, the pneumococcus in 
pure culture was found as the infecting agent. 

TUBERCULOUS PERITONITIS 

In tuberculous involvement of the peritoneum the disease is 
usually well advanced by the time it comes into the hands of the 
pediatrist. The chief question that concerns us at the present time 
is as to the advisability of the operation of laparotomy. 

When to Operate. — My course is as follows: If there is marked 
ascites with much discomfort, operation is advised at once. It 
would seem that early operation furnishes the best chance for re- 
covery in the actively acute cases. When there is evidence of in- 



492 DACTYLITIS 

terference with normal peristalsis, as indicated by persistent consti- 
pation and visible peristalsis, it means that intestinal obstruction is 
imminent, and immediate laparotomy is advised. When the above 
conditions do not obtain, I have found it advisable to postpone ope- 
ration and attempt to relieve the patient by hygienic measures, diet, 
and medication. 

Some of the cases seen by me were absolutely hopeless at the 
time, showing marked tuberculous processes elsewhere, and there- 
fore were not considered fit subjects for operation. In the non- 
surgical treatment of these cases the chief points of importance 
to be considered are nutrition, fresh air, and a thorough daily bowel 
evacuation. 

As long as there is a temperature above ioo° F. or abdominal 
pain, the patient should be kept in a recumbent position and out 
of doors. Moderate exercise is to be encouraged as soon as the 
conditions allow. The same methods of constitutional treatment 
as to diet and climate are to be followed out as are laid down in the 
treatment of Pulmonary Tuberculosis (page 299). The patient 
should be weighed once a week, and in case of a continuous loss 
in weight and strength extending over five or six weeks, with or 
without fever, in spite of the advantage of diet and climate, oper- 
ation is advised, regardless of the stage of the process, provided 
always there is no active tuberculous process elsewhere. When 
the weight remains stationary or nearly so for two or three months, 
laparotomy is advised. In the event of improvement and gain 
in weight, the expectant treatment is continued. 

Illustrative Case. — The necessity for operation cannot always be 
convincingly impressed upon the parents. A few years ago the con- 
dition of a private case, a boy three years of age, was persistently 
bad. There was moderate fever, emaciation to a marked degree, 
with later, tubercular involvement of two of the dorsal vertebrae. 
Laparotomy was suggested early in the illness, but it was refused, 
and the child after a prolonged illness made a complete recovery 
both from the tuberculous peritonitis and the tuberculous caries 
of the vertebrae. In this case I am convinced that an unnecessary 
risk was taken, and that recovery from the peritonitis would have 
been much more rapid and the vertebral involvement probably 
prevented by an early laparotomy. 

DACTYLITIS 

Dactylitis consists of a fusiform swelling on one or more of the 
phalanges of the fingers. It may be of two forms, dactylitis syphi- 
litica and dactylitis tuberculosa. The differentiation between the 
two conditions is oftentimes most difficult. In the syphilitic type 
the lesions are more apt to be multiple and are associated with 
syphilitic lesions elsewhere. Furthermore, these cases are favorably 



TUBERCULOUS BONK DISEASE. GLANDULAR FEVER 493 

influenced by anti-syphilitic treatment, which is not the case with 
the tuberculous form. 

Aside from the anti-syphilitic treatment, the management of 
the two forms is the same. Absolute rest to the parts appears to 
be essential for successful treatment. This is best secured by the 
use of splints, which must be kept bound on the fingers for months 
in such a way as effectually to immobiUze them. In a recent case 
of the tuberculous form, successfully treated in this way, the fin- 
ger was kept in splints for six months. When abscess and necrosis 
occur, the case must be treated along surgical lines, the immobility 
of the parts being maintained as completely as the conditions allow. 

TUBERCULOUS BONE DISEASE 

Children afflicted with tuberculous bone disease, whether in the 
spine, the hip-joint, the knee-joint, or elsewhere, should be in the 
hands of the general or orthopedic surgeon. The constitutional 
treatment of these cases, however, is most important, and is largely 
along nutritional and hygienic hues, for the better the nutrition 
and the physical condition of the patient, the more complete and 
prompt will be the results of the surgeon's efforts. 

Diet. — A tuberculous child should receive a generous amount of 
fat and nitrogenous food. There should be no forced feeding, as this 
almost invariably makes the child ill, or he will become disgusted with 
all food. What is required is a liberal supply of properly selected, 
properly prepared food. The diet advocated in the Tardy ]\Ialnu- 
trition cases and in Pulmonary Tuberculosis should be employed 
here. The five meals a day which are often advocated for tuberculous 
children, I have been unable to give with advantage. The most fre- 
quent feedings that I have been able to give with benefit for children 
of three years or over are the three daily meals, with a glass of milk 
or cocoa in the middle of the afternoon. As much outdoor life 
as is possible should be afforded the patient. City children always 
improve more rapidly w^hen placed in good surroundings in the 
country. 

GLANDULAR FEVER 

Glandular fever is usualh" seen in children after the first year. 
The disease is due to a local infection the nature of which is unknown. 
The lymph-nodes at the angle of the jaw are involved, forming 
an elongated tumor between the angle of the jaw and the sterno- 
mastoid which may reach a considerable size. I have seen cases 
during the past winter in which the tumors were as large as hens' 
eggs. Both sides are usually involved; the swelling is first noticed 
on one side, which is often followed by an enlargement of the glands 
on the opposite side. 

The symptoms are fever, usually from ioi° to 104° F., prostra- 
tion, and loss of appetite. The disease is to be differentiated from 



494 CYCLIC VOMITING 

mumps in that the parotid glands are not involved, and from acute 
simple adenitis by the absence of throat involvement, and in the 
fact that nearly all cases recover without suppuration or resulting 
persistent adenitis. In several of the cases seen during the winter 
and spring of 1906 the rhinopharynx was normal. 

The treatment consists in the continuous use of ice-bags or the 
cold compress (page 333), and laxatives, such as milk of magnesia or 
citrate of magnesia, sufficient to produce one or two evacuations 
daily, a reduced diet of broths and gruels, and keeping the patient 
in bed. The swelling may last from five days to two weeks, and 
in my cases has subsided without suppuration. 

CYCLIC VOMITING 

Recurrent attacks of persistent vomiting are frequently seen 
by the pediatrist. An attack comes on suddenly with little or 
no warning. At first the contents of the stomach are vomited; 
later, in many cases, whatever may be taken in the line of food or 
drink. When no food is taken, the dry retching and vomiting of 
mucus continue, the latter for a few hours, for an entire day, or 
for several days. The most prolonged case under my observation 
was in a boy three years of age, who vomited persistently for thir- 
teen days. The cessation of the vomiting is usually as abrupt as 
its onset, the patient asking for and retaining the nourishment 
which is given him. If the attack is a short one and mild in char- 
acter, the customary diet will usually be taken at once thereafter 
without inconvenience. If the attack has been prolonged, with 
much straining and vomiting of mucus streaked with blood, or 
if there has been a decided hematemesis, which I have seen in some 
cases, the resumption of the feeding will necessitate considerable 
care. In such cases broths, kumyss, and bland non-irritating articles 
of diet generally will have to be given. 

Treatment. — According to my observation direct medication to the 
stomach during the attack is valueless. Our efforts are best exerted 
in maintaining the nutrition of the patient. All attempts at supply- 
ing water or food by the stomach should be discontinued. Nutrient 
enemata and colon flushings are invaluable in all of the prolonged 
cases — those lasting over forty-eight hours. In addition to the 
discomfort produced by the vomiting, these patients suffer greatly 
from thirst. The necessary amount of fluid can be supplied by colon 
flushings. For a child five years of age one pint of normal salt solution 
may be introduced into the colon through an ordinary rectal tube 
(page 219). I have often known patients to retain as much as 
two pints of fluid a day when it was thus given. If the case promises 
to last more than three days, it is best to begin with nutrient enemata 
on the third or fourth day. For this purpose I employ from six 
to eight ounces of completely peptonized skimmed milk, to which 



CYCLIC VOMITING 495 

the whites of two eggs have been added. This is given at eight- 
hour intervals. The use of the sah solution and peptonized milk 
furnishes sufficient fluid nutriment to sustain the child until the 
vomiting ceases. In two cases only have I been obliged to resort 
to morphin hypodermatically, to control the frequency and violence 
of the vomiting attacks. 

All of my cases of cyclic vomiting — and I have treated over 
thirty of them — have been without exception in children of rheu- 
matic inheritance or in those in whom rheumatism was evident 
by some unmistakable sign. It is therefore of great advantage 
to consider these cases and treat them as though they were of rheu- 
matic origin. The attacks, perhaps, may not be entirely prevented, 
but in practically every case they may be delayed by putting the 
patient upon suitable treatment in the inter^^als. My custom is 
to give only a limited amount of animal proteid and a diet scanty 
in sugar or with sugar entirely excluded if the case is a severe one. 
The use of green vegetables, fruits, and cereals and milk is encouraged. 

To a child of from three to ten years of age, from nine to twelve 
grains of salicylate of soda or aspirin are given after meals daily 
in divided doses, for five days out of every fifteen. During the 
ten days of rest from the salicylate, five grains of bicarbonate of 
soda are given twice daily between meals. This scheme of treatment 
is continued for months. If the salicylate of soda interferes with 
digestion or with the appetite, aspirin in equal dosage is substituted. 
By following this method of treatment in cases where attacks had 
been occurring every month or six weeks, the intervals between them 
have been increased to six months or a year, and in several instances 
the attacks have entirely ceased. Spasmodic treatment of these cases 
is of little value; only persistent treatment is effective, and there 
must be confidence and cooperation on the part of the family or 
any treatment will fail. 



TEMPERATURE IN CHILDREN 

Normal Temperature.— The question is often asked: What is 
the normal temperature of a baby or young child of a given age? 
In order to answer this question from our own observation, a study 
of the matter was carried out at my suggestion by Dr. H. G. Myers, 
resident physician at The New York Infant Asylum. This study 
comprises fifty-nine cases, the ages varying from birth to one year. 
Only well children were selected for the observation, the majority 
being breast-fed. The temperatures in each instance were taken 
by the rectum for four minutes. 

It was found in these infants that the birth temperature ranged 
from 96° to 98° F., exceeding 98° F. in but five cases, when it was 
between 98° and 99° F. In one it was 94° F, During the twenty- 
four hours following birth there was a rise in the temperature usually 
of about one degree. From this time on, there was little varia- 
tion in the temperature, when the child was well, regardless of the 
age. There would be a variation at different times of the day of 
a fraction of a degree, it being higher in the evening. Upon looking 
over the charts upon which the results were chronicled, one is im- 
pressed by the uniformity of the temperature, ranging, as it does, 
within fairly narrow limits, from 98° to 99.2° F. 

Instances when the temperature arose to 99.5° F. were occasionally 
seen, but 100° F. was very unusual. It is not claimed that the tempera- 
ture of a well child may not reach 100° F. ; in fact, there were occa- 
sions when it rose to 101° F. and illness could not be proved, and 
had not the temperature been taken for the purpose above men- 
tioned, no elevation would have been suspected, for when next taken 
the temperature was normal. In those cases in which a rise was 
proved to be an early sign of illness, the recording of the tempera- 
ture was discontinued and the first reading was not included in the 
observations. In one child a temperature of 103° F. was found. It 
remained at this point for three hours, when it fell to normal with- 
out any other manifestation of trouble. When, however, the ther- 
mometer registered over 99.5° F., some cause for the elevation could 
usually be discovered; though it may have been nothing more 
than excitement or a sHght indigestion. 

Several years ago I personally made a similar series of observa- 
tions at the Country Branch of The New York Infant Asylum in 
twenty-five healthy children under eighteen months of age. The 
temperatures were taken four times a day, the observations extending 
over an entire week. It was found in these well children that the 

496 



TEMPKRATURB IN CHILDREN 497 

temperature varied from 98° to 99° F. ; when it rose every day above 
99.5° F., some abnormal condition was always found to explain it. 

Judging from these observations in seventy-four well children, 
ranging in age from birth to eighteen months, whose temperatures 
were taken several hundred times, it would seem that a daily rise 
above 99.5°, F. may be considered abnormal. An occasional rise, 
however, considerably higher than this, as above mentioned, may 
occur and does occur in perfectly healthy children, without being 
of any special significance. 

Fever. — By fever, then, in infants and children we understand an 
increase above that which is considered the normal body-temperature. 

In children, for clinical purposes, the rectal temperature should 
always be taken. For those under five years of age the mouth is 
unsafe, because the child is apt to bite off the thermometer bulb, 
and unreliable, because the lips will not remain closed the requisite 
three or four minutes. The axillary temperature is thoroughly 
misleading and should never be depended upon. Thermometers 
should be carefully disinfected with alcohol after using. One- 
minute thermometers, according to my observations, are often 
unreliable and should not be used. 

The highest temperature personally known to the writer was 
111° F. This was as high as the thermometer could register. It 
occurred in a child of ten months who was in a convulsion, which 
was one of the first symptoms of a tuberculous meningitis. The 
child had been placed by the parents in water at a temperature of 
115° F. It had been in the water about ten minutes before the 
rectal temperature was taken. How much the temperature was due 
to the illness and how much to the hot water will never be known. 
The temperature responded promptly to a cold bath. The child never 
regained consciousness and died of meningitis ten days after the 
initial convulsion. 

Fever may or may not be an index of the gravity of a disease; 
thus we frequently have a temperature ranging from 103° to 105° 
F. in tonsillitis, acute indigestion, and stomatitis — ailments which 
respond very quickly to treatment and which present no serious 
aspects. In typhoid fever, pneumonia, scarlet fever, and diph- 
theria, however, when the temperature range is above 104° F., it 
is a symptom of considerable value, as indicating the severity of 
the infection; so that it is not the fever itself, but the condition 
back of and associated with it, which makes it a sign of clinical 
value. In pneumonia, children bear a comparatively high tem- 
perature, 104° F., for example, without much discomfort or danger; 
while in the acute intestinal disorders of summer, an equal degree 
of fever is borne very badly, and if continued is of grave signifi- 
cance. This must be kept in mind in our dealings with fever. 

When is a given temperature to be interfered with? is a ques- 
32 



498 TEMPERATURE IN CHILDREN 

tion which concerns all practitioners. This depends to a great 
extent upon the cause of the fever and its effects upon the patient. 
If the fever produces diminished assimilation, loss of sleep, irri- 
tability, and restlessness, it will do the child harm by diminishing 
the normal resistance to disease, and should be relieved whether 
it is 102° F. or 105° F. It will thus be seen that interference is 
dependent not so much upon the height of the temperature as upon 
its effects upon the patient. 

The methods of reheving fever are: (i) Elimination: This ap- 
plies particularly to the gastro-enteric tract and the skin. In a 
majority of the cases of high fever due to an acute indigestion with 
resulting toxemia, a purgation, a bowel- washing, and a carefully 
adjusted diet for a day or two, and the case is well. We remove 
the cause of a fever, and the fever subsides. Unfortunately, this 
means of controlling fever is limited to the gastro-enteric tract. 
(2) Diaphoresis, by which is understood the production of an exces- 
sive perspiration, will also relieve high temperature. The most 
reliable way of bringing this about in a child is by the use of mod- 
erately heavy covering and the administration of the tincture of 
aconite, in doses of one-half to one drop every hour, — eight doses 
in twenty-four hours; or liquor ammonii acetatis, two drams every 
two hours, for a child one year old. (3) Hydrotherapy: By far the 
most satisfactory means of controlling fever depends upon the local 
abstraction of heat by means of sponging (page 502), tub-baths (page 
30), and cool packs (page 503). (4) Antipyretic drugs: Much which 
borders on the sensational has been written about the harmfulness 
of antipyretic drugs, particularly the coal-tar products. Used in 
large and frequent doses, they certainly may do a great deal of 
damage ; under certain conditions, used in small doses and repeated 
at intervals of from three to six hours, they may be and often are 
of benefit. Aconite and the Hquor ammonii acetatis are of some 
value, as above stated, but they are of Httle value in controlling 
a very high persistent temperature. The coal-tar products furnish 
the best antipyretic drugs and may be used with safety, but should 
be used only when, for any reason, the local abstraction of heat 
by the appHcation of cold is impossible. In many families there is 
too Httle intelHgence to make a cold pack either possible or safe. 
In severe cases of pneumonia and scarlet fever, and in the intestinal 
diseases, sponging often will not answer. Only a trained nurse 
or a very intelligent mother should be entrusted with a pack. More- 
over, sponging and tub-bathing, if repeated too frequently, particu- 
larly during the night, exhaust the child. Spongings or tub-baths 
are often strenuously objected to by parents as well as by the patient, 
and if the nurse is one of the family, her sympathy will counter- 
balance her judgment, and the result be far from satisfactory. 
Under such conditions, when the appHcation of cold to the skin 



OBSCURE ELEVATIONS OF TEMPERATURE 499 

is impossible, a combination of ptienacetin and caffein, alone or 
with Dover's powder, has proved effective. The antipyretic treat- 
ment of scarlet fever is the same as that of pneumonia or typhoid 
fever. 

My use of antipyretic drugs has been confined almost entirely 
to the ignorant in private work, and to dispensary patients. For a 
child of one year or under, one grain of phenacetin with one-fourth 
grain of citrate of caffein may be given and repeated at three-hour 
intervals if the temperature requires it. For a child two years of age 
i^ grain of phenacetin and ^ grain of citrate of caffein at three-hour 
intervals; three years and over, i^ to 2^ grains of phenacetin with ^ 
to I grain of citrate of caffein, at intervals of from three to six hours. 
If there is much restlessness and irritability which is not thus con- 
trolled, Dover's powder may be added — j grain to each dose, 
for a child of from three to six months of age; ^ grain between 
six and twelve months; one grain after the age of two years is 
reached. It is always wise to caution parents as to the use of Dover's 
powder in children. They should be told that if the child becomes 
"heavy," or difficult to arouse, the powders must be discontinued. 
That phenacetin and citrate of caffein cannot be given in solution is 
unfortunate. Like all insoluble powders, they are best given in 
some mucilaginous mixture, such as barley-water or one of the 
cereal jellies. Fruit-juice or apple-sauce usually answers well. 
Antipyrin, for the reason that it forms a tasteless mixture with 
water, succeeds better with some intractable children, and may be 
used in the same doses as phenacetin; although as an antipyretic 
it is less efficient. 

OBSCURE ELEVATIONS OF TEMPERATURE 

Perhaps the most annoying cases in pediatric work are those 
with an elevation of the temperature for which no adequate cause 
can be discovered. In the section on Normal Temperature cer- 
tain possible variations are given which I regard as within the 
limits of health. When these boundaries are passed, when there 
is a temperature range between 99° and 101° or 102° F., or a tem- 
perature persistently at 100° or 101° F. without any apparent cause, 
and continuing for days and weeks, the medical adviser is not in 
an enviable situation. Such cases coming to the pediatrist through 
consultation or otherwise are sometimes easy of solution. At 
other times, however, the cause of the fever may never be discovered, 
and the patient eventually gets well, leaving us still in ignorance of 
the cause of the fever. 

Active Exercise in Nervous Children. — This is not infrequently 
the cause of an elevation of the temperature. I have seen several 
cases of this nature. A few years ago I saw in consultation a country 
child three years of age, whose temperature every afternoon at one 



500 TKMPKRATURE IN CHILDREN 

o'clock was i02° F. The child, while not vigorous, showed no 
signs of illness. He ate well, slept well, and played hard. There 
was a slow gain in weight. The fever was discovered by the mother, 
who thought that the child, who was a blonde, looked flushed every 
day at about the same time. The temperature by rectum was nor- 
mal in the morning and normal at night. This condition, to the 
attending physician's knowledge, had persisted for six weeks before 
I saw the patient. How long there had been a daily elevation of 
the temperature above the normal before the mother discovered 
it, we have no means of knowing. The doctor, an excellent prac- 
titioner, had suspected, examined the child for, and treated him 
for various diseases; the first being malaria, with no response to 
quinin; then typhoid fever, as by suggestion and constant inquiry 
the child came to imagine that he must be sick, and complained 
of languor. The fever continued, however, beyond the usual time 
allowance for typhoid fever and there were no other symptoms. 
There was no enlargement of the spleen and the blood had been 
repeatedly found negative to the Widal reaction. Other possible 
causes of the fever were also given attention. One day the doctor 
suggested tuberculosis. This aroused the family and friends 
and a consultation was the immediate result. In company with 
the doctor, I saw the child at its home. I found a rather thin 
blond boy, three years old. The family history was excellent. 
There was one other child, six years of age, who was well and a 
good specimen of robust boyhood. The patient had never had a 
pulmonary disorder and no disease of the respiratory tract other 
than slight bronchitis. There was no apparent association of the 
condition with any intestinal or infectious disease. An exhaustive - 
physical examination failed to reveal any abnormality other than 
a small umbilical hernia and a slight enlargement of the inguinal 
and submaxillary glands. The blood was not examined. The 
child was pale and doubtless a blood examination would have 
revealed a mild secondary anemia. The appetite was fairly good; 
the bowels were reported regular and his stools normal. The child 
had not been kept in bed, as the family did not consider him very 
ill. The physical examination being negative, I questioned the 
mother very closely as to the child's habits of Hfe. I found that 
he rose at 7 a. m., had breakfast at 7.30, played with his big brother 
and two older boys until one o'clock, when he had dinner. A glass 
of milk and a piece of bread and butter were given as a luncheon 
at II A. M. I found that he played very actively, kept up with the 
older boys, and was unhappy when he was not with them. At- 
tempts had been made without success to entertain him with less 
strenuous play. It was at midday, sometimes before, sometimes 
after dinner, that the temperature reached the highest point. It 
seemed to me that here, probably, was a case of fatigue temperature. 



OBSCURE ELEVATIONS OF TEMPERATURE 50I 

I accordingly suggested that the boy be undressed and put to bed 
at 1 1. 1 5 A. M. after the Hght luncheon and be made to rest and 
sleep if possible. At 1.15 he was to be taken up for dinner, his 
temperature first being taken. These instructions were faithfully 
carried out, and I am pleased to state that this ended the daily 
rise in temperature. The case was one of an active, nervous child 
becoming overtired in his attempts to hold his own with older and 
stronger boys. The patient improved rapidly in his physical con- 
dition and is now, after an interval of three years, perfectly well. 

Another child, four years of age, was seen in consultation with 
a New York physician, because of a daily elevation of the temper- 
ature to from 100° to 102.5° F., which had continued for six weeks. 
The child was thriving and otherwise perfectly well. No cause 
of the fever could be discovered in his physical condition. He 
had a noisy, excitable nurse, who was inclined to exciting games 
and rough play with the boy. With a dismissal of the nurse the 
fever ceased. 

Otitis. — Persistent fever, following the acute catarrhal affec- 
tions of the upper respiratory tract and the exanthemata, is 
sometimes explained by a suppurative process in the middle ear, 
without other symptoms than the fever. 

Encysted Empyema. — A small area of encysted empyema may 
explain a persistent fever, following pneumonia. Holt describes a 
most interesting case of this nature in which there was for over 
four weeks a temperature range from 100° to 105° F. Autopsy 
showed a small collection of pus between the diaphragm and the 
lung. 

Periodic Fever. — Not infrequently we see cases which show 
some of the clinical signs of malaria as regards periodicity in the 
temperature, but without splenic enlargement, or the presence 
of the malarial organism in the blood. Yet, often, these cases quickly 
respond to full doses of the bisulphate of quinin. 

Typhoid Fever. — Occasionally a case with low persistent tem- 
perature elevation, obscure for a week or two, proves to be a mild 
typhoid. 

Tuberculosis. — An elevation of the temperature is sometimes 
the first premonitory symptom of tuberculosis. Tuberculosis in 
a child, however, is usually an active process when it involves the 
lungs, and can readily be made out. When other parts are involved, 
such as the bones, glands, skin, or peritoneum, the manifestations 
are usually sufficiently plain to indicate the condition. 

Intestinal Infection. — Intestinal infection of a latent type may 
be the cause of persistent fever. In a suspected case in the 
absence of bowel symptoms, it is well to give a laxative and put 
the child temporarily on a reduced diet consisting largely of carbo- 
hydrates. 



502 TEMPKRATURK IN CHILDREN 

Unexplained Elevations of Temperature. — I have known children 
to run an unexplained temperature of from ioo° to 101.5° F. for 
weeks, without any other sign of illness. I have had these cases 
examined by eminent consultants and I have seen them recover 
without a diagnosis. Of one thing, however, we may rest assured: 
If a competent, thorough examination of the patient does not reveal 
the cause of the temperature, we are safe in concluding that there 
is nothing of a very serious nature back of it. 

Illustrative Case. — The history of a case of this kind, which gave 
me no end of trouble and annoyance, may not be without interest. 

The patient, an eight-year-old boy, was the only son of a habit- 
ually anxious mother, who had unfortunately learned to use the 
clinical thermometer. She took her boy's temperature after school 
one day early in December. She found that the thermom^eter 
registered 100.5° ^' I was consulted, saw the boy in the evening, 
took his temperature, by mouth, with my own thermometer, and 
found it 100.8° F., with no other evidence of disease. He was per- 
fectly normal in every other respect. He maintained that he felt 
well, did not need a doctor, and wished to be let alone to study 
his lessons. The following morning the temperature was 100° F. ; 
in the evening it was nearly 101° F. For six weeks this temperature 
range continued, never below 100° F., never higher than 101.2° F. 
The boy, against my advice, was taken from school. He was put 
to bed, and a half-dozen consultants saw him without shedding 
any light on the case. Finally the mother became reconciled to 
"doing nothing " for her son, and he was taken to a nearby winter 
resort. I suggested to the father that before leaving town he should 
''accidentally" drop the thermometer on the hardwood floor and 
then refuse to have another in the house. This he managed to do, 
straightway. The boy had an excellent time at the winter resort, 
played with his sled in the snow, skated on the lake, fell through 
the ice once and received a thorough wetting, without harm. In 
three weeks he returned, improved as much as any city child improves 
from a country outing. His temperature was not taken during these 
three weeks at the winter resort and has not been taken since, except 
where there were evidences of illness. He is now developing along 
normal lines and is a fair physical specimen for his age. 

COLD SPONGING IN FEVER 

Sponging with plain water, with salt water (a teaspoonful of 
salt to a pint of water) , or with alcohol and water (one-fourth alcohol 
to three-fourths water) is a means of reducing high temperature 
with whic;h every physician should be familiar. Cool sponging, 
75° F. to 80° F., plain or medicated, is useful for two purposes: 
as a sedative and for the reduction of fever. In measles or scarlet 
fever, although the temperature may not be high, the itching and 



THE COOIv PACK 503 

burning of the skin prevent sleep, and the patient is very uncom- 
fortable, but often, under such conditions, he will fall asleep during 
a careful sponging. In pneumonia, in typhoid fever, and in the 
intestinal disorders of summer, my nurses have a standing order 
to give a cold sponging for fifteen minutes at any time when, in their 
judgment, it may be indicated, not on account of the fever but 
because of its sedative effect upon the patient. A sponging of from 
ten to fifteen minutes three or four times a day with cool water, 
65° to 75° F., will greatly help a baby, whether sick or well, to pass 
successfully through the hot days of summer. 

Sponging for fever, while possessing less antipyretic value than 
do other measures, such as a cold pack, for example, has the advan- 
tage in that it is safe and easy of application in the hands of the 
most unskilled, and will be of assistance in controlling high tem- 
perature when other means are not available. In order not to antag- 
onize or frighten timid children, it is often wise to begin with the 
water, whether plain or medicated, at 95° F. and reduce the temper- 
ature gradually by the addition of cold water or small pieces of ice. 
It is rarely necessary to go below 60° F., and usually the sponging 
should not be continued longer than thirty minutes. It is well 
to have an interval of rest — from thirty to ninety minutes — between 
the spongings, as too frequent sponging, if resisted, may exhaust 
the patient. Every part of the body should be sponged in turn, 
but it is not necessary to expose the patient, who should be covered 
with a flannel blanket. When the process is completed the skin 
should be briskly rubbed for a few minutes with a dry, rough towel. 

THE COOL PACK 

The cool pack properly applied is without the slightest danger 
to the patient and is the best means we possess with which to comi- 
bat a continued high fever. It may be used as freely and with 
as much success in the exanthemata as in typhoid fever or pneu- 
monia. That cool water may not safely be applied to the skin of 
a child with scarlet fever or measles is a fallacy which it is our duty 
to explain to mothers. 

The pack is prepared as follows, a rubber sheet being used to 
protect the bed-sheet: A large bath towel or some thick, soft, absorb- 
ent material should be used ; muslin, Hnen, or any thin material does 
not answer as well. Slits are cut in the towel large enough for the 
arms to pass through and the towel is folded around the body, 
enveloping only the trunk and buttocks (Fig. 61). The pack should 
not extend below the middle of the thighs. This leaves the arms 
and the greater part of the lower extremities free. A hot-water 
bag, carefully guarded, should be placed at the feet and the patient 
covered with a blanket of medium weight. The towel is moistened 
with water at 95° F. This higher temperature is necessary at first 



504 



TKMPERATUR]^ IN CHILDREN 



in order not to frighten the patient, as sudden cold is apt to do, 
and also to avoid shock. In two or three minutes the towel, without 
being removed, is again moistened with water at 90° F., later with 
water at 85° F., and still later at 80° F. When the temperature 
of the water reaches 80° F., it is better to hold it at this point 
for half an hour, when the patient's temperature should again be 
taken. If at the beginning his temperature was 105° F. and now 
shows but slight or no reduction, the temperature of the water 
with which the towel is moistened should be reduced to 70° F., or 
if necessary, even to 60° F. The child throughout need not be 
disturbed, except to turn him from side to side to wet the towel 
with water of the desired temperature, this being one of the advan- 
tages of the pack over a tub-bath or sponging. 

For the first hour or two in a pack the temperature of the pa- 
tient should be taken every half hour. When it is reduced to 102° 
F., the pack should be removed, for, if it is continued longer, too 




Fig. 61.— The Cool Pack. 



great a reduction may take place. If it rises again rapidly to 105° 
F. or higher, it is well to keep the patient in the pack continuously. 
The degree of cold necessary, in the individual case, to keep the tem- 
perature within safe limits will soon be learned. I recently kept in 
a pack for seventy-two hours a boy four years old, with a lobar 
pneumonia. In this case a continuous pack of 70° F. was required 
to keep the temperature at 104° F. or sHghtly lower. The towel, 
or other material employed, should not be used for more than six 
hours, when it should be changed for a fresh one. 

Another reason for frequently taking the temperature is that 
early in the attack we do not know how it will be affected by the 
continued cool applications. In some children it is very readily 
influenced, and in such a case collapse might follow a very sudden 
reduction of the temperature. In cases readily controlled, the pack 
may be necessary for only one-half hour or an hour, at intervals 
of three or four hours. An ice-bag may with advantage be kept 



BATHING THE SICK 505 

at the head when the child is in the pack. Suddenly enveloping 
the entire skin surface in a cold sheet at 70° F., as advocated by 
some writers, may increase the temperature and produce grave 
symptoms of impending death because of the sudden contraction 
of the superficial blood-vessels, which sends the blood to the vis- 
cera, producing congestion of the internal organs. 

BATHING THE SICK 
There is a pronounced objection among many to bathing children 
when ill, particularly when they are suffering from respiratory 
diseases or from the exanthemata. The functions of the skin as an 
organ of excretion and elimination are most important, and it is 
absolutely necessary that, during illness, when oftentimes the 
metabolic processes of the body are being carried on to an exces- 
sive degree, all the eliminating organs be kept in the best pos- 
sible condition in order that they may the better do their work. 
Therefore to have the skin perform its functions properly it must 
receive proper attention, and there is no better means for stimu- 
lating it to a sharp reaction than bathing with weak salt water 
— a teaspoonful of salt to a gallon of water — at a temperature 
of 85° to 90° F., followed by a brisk rubbing. Every sick child 
should receive a sponge bath at least once daily. It is the sudden 
contact of cold air with the moist skin, which occurs sometimes 
in undressing a child, without the attendant reaction, that causes 
the shock, the "cold," which is usually attributed to the bath. 
It is the temperature of the room in which the child is undressed, 
the careless method of bathing, and not the application of water 
which cause the trouble. Even the danger of this exposure is 
greatly overestimated. In order to avoid every possible danger, 
however, the temperature of the room in which the sick or delicate 
child is bathed should be raised to 80° F. I have yet to know of 
a child who suffered from the effects of a bath properly given, and 
I know of hundreds who have suffered because of the absence of it. 



VACCINATION 

Every infant in fair health should be vaccinated. The vaccina- 
tion should be done as soon as the child is thriving on a rational diet. 
The younger the child at the time of vaccination, the less the consti- 
tutional disturbance. In well infants, vaccination should never be 
delayed beyond the fifth month. 

The Site. — The site selected for the vaccination is usually on the 
left arm in boys, at about the point of insertion of the deltoid, and in 
girls on the outer aspect of the calf of the leg. I have found, how- 
ever, that it is a matter of much more convenience to the mother in 
dressing and handling the child, if the leg is selected in both sexes. 
The dressing is more easily applied to the wound and can the more 
readily be kept in place on the leg. Further, in the manipulation 
necessary in dressing and undressing, much less discomfort is occa- 
sioned when the sore is on the leg. 

The Method. — Before scarification of the skin, the site selected 
should be well scrubbed with common soap and water, dried, and 
then washed with alcohol. The area of scarification should not 
be over one-quarter of an inch in diameter, and should be suffi- 
cient to produce only a light flow of serum. A deep scarification, 
producing a free flow of blood, is very apt to be unsuccessful. The 
best scarifier is an ordinary sewing-needle, which should be sterilized 
by placing the point for a few seconds in an alcohol flame. The 
virus which is furnished in hermetically sealed capillary glass tubes 
is the safest to use. The drop of virus is deposited on the abraded 
surface and rubbed well into the wound, using the side of the needle 
for this purpose. When the wound is thoroughly dried, a protective 
dressing should be applied. The safest and most convenient is a 
sterile gauze bandage, which is wrapped several times around the 
arm or leg and secured with a safety-pin. On account of the shape 
and position of the parts, the bandage is very apt to become displaced, 
downward. In order to prevent this, a strip of adhesive plaster one 
inch wide and five or six inches long is placed over the bandage at 
right angles to it. The middle portion of the plaster readily adheres 
to the bandage and the two ends, at least two inches long, are an- 
chored to the skin. 

The After-treatment. — The mother is instructed to report in seven 
days after the vaccination. On the seventh day the dressing is re- 
moved, and if the vaccination is successful, the characteristic pearl- 
like vesicle will be present. If, on account of accident or rubbing of 
the parts by the patient, the vesicle is broken, the non-adhering 

506 



VACCINATION 50? 

gauze should be carefully cut away around the sore, allowing that 
which adheres to remain. Under no conditions should the wound 
be opened. A gauze dressing is again appHed and kept in position 
by adhesive strips. At the end of the exudative stage, usually about 
five or six days, the dressing should again be changed, either by 
the mother or the physician, and continued until the crust falls, 
which will be from the third to the fourth week after the vaccina- 
tion. 

If there is no sign of the vesicle in ten or twelve days, the vaccin- 
ation, if primary, should be repeated. Re- vaccination should be 
practised at least once in five years and at more frequent intervals 
during epidemics of smallpox. 

Complications. — ^If vaccination is properly performed, the 
dangers attending it are practically nil. That death and serious 
results have followed vaccination is no argument against its use, but 
is a grave reflection on the manner in which, as a rule, it is performed. 
The scarification of bacteria-laden skin, producing at the outset an 
open wound which is indifferently or not at all protected from further 
infection, is very apt to produce complications of a troublesome and 
often serious nature. Erysipelas, extensive cellulitis, and sloughing 
of the parts as the result of careless vaccination are not infrequently 
seen at out-patient departments for children. I have seen in two 
cases a reinoculation, as the result of scratching the sore, thus trans- 
ferring the virus in one case to the upper lip and in the other to the 
left upper eyelid, these places being the site of the vaccination sore. 

Vaccination Shield. — There is not a vaccination shield on the 
market with which I am familiar that is safe for use. Some cause 
a maceration of the wound, others allow a free entrance of bacteria, 
while still others prevent a free superficial circulation of the blood 
and increase the chance of ulceration. ^Moreover, the shields are 
very apt to become displaced, causing a rupture of the vesicle, with 
resulting infection. 

Constitutional Disturbance. — A certain degree of constitutional 
disturbance is present in every child in which the vaccination is 
successful. After the first month, however, the younger the child, 
the less the constitutional disturbance. Children vaccinated during 
the second or third month suft'er practically no inconvenience. There 
is a rise in temperature, from ioo° to ioi° F., for a day or two, and 
when the process is at its height, perhaps a slight degree of restless- 
ness. Time and again I have seen children, vaccinated at this age, 
pass through the various stages without manifesting the slightest 
discomfort. In older children the severity of the constitutional 
symptoms appears to increase with the age. Thus, a child in the 
second or third year may have fever, 102° to 104° F., loss of appetite, 
coated tongue, and moderate prostration. Very active symptoms 
rarely last longer than three days unless there is a considerable 
accompanying cellulitis. 



508 VACCINATION 

Local Applications. — Active treatment, other than relieving the 
immediate constitutional symptoms, is rarely required. Even when 
there is an active cellulitis I have found it advisable not to attempt 
local applications, such as lotions or compresses. All ointments 
have a tendency to dissolve and loosen the crust, producing an open 
wound. When, on account of suppuration, the crust falls, leaving 
a deep ulcer formed by granulation tissue, active local treatment 
will be required. Such ulcers are often seen in out-patient work. 
A wet dressing of a saturated solution of boric acid has answered 
well in these cases. If the wet dressing cannot be kept properly 
applied, a lo percent ointment of boric acid may be applied twice 
a day and will be found of considerable service in hastening the 
closure of the wound. The ointment should be smeared freely on 
gauze or clean linen and held in position by a properly applied 
bandage. In young children the ulcers are often most obstinate. 
In a few instances I have known them to continue from eight to ten 
weeks. In a case in which the healing is particularly slow, the 
familiar dressing of balsam of Peru (5 percent) in castor oil, appHed 
twice daily on a pad of several thicknesses of gauze and covered 
with oiled silk, has appeared to hasten the granulation. Unhealthy 
granulations may have to be curetted before the dressing is applied. 



INSTRUCTIONS FOR THE SUMMER 

In addition to advising parents as to a selection of a summer re- 
sort for the family, I advise the mother as to the particular care of 
the child during the summer whether he is to remain in town or go 
to the country. During the months preceding the heated term 
every mother whose infant is under my care, whether in dispensary 
or private, is made aware of the dangers of the next few months, 
and means are suggested and written directions are given as to how 
to pass through the summer with the greatest security. She is 
told what market milks are the best. She is told that the milk 
must be kept on ice, with ice surrounding the bottle, from the time 
of its delivery until it is given to the child, except, of course, the 
time spent in its special preparation. 

During the hot months in New York city the child's digestive 
capacity is not equal to that of the colder months. Children who 
remain in the city are given weaker milk mixtures by a reduction of 
from 15 to 25 percent in the fat and proteid, the sugar remaining 
the same. True, the infant may not gain very much in weight, but 
on a reduced diet he is much more apt to pass through the summer 
without intestinal disorders, and there is an abundant opportunity 
for him to gain later on. Mothers are instructed as to the amount 
of clothing required. They are told that a napkin, a muslin slip, a 
loose-mesh knitted band, are all that are required, on very hot days. 
They are instructed to give the infant frequent drinks of boiled 
water between his feedings, and if he suffers much from the heat, as 
shown by prickly heat and restlessness, to give him two or three 
spongings daily with a cool solution of bicarbonate of soda, one tea- 
spoonful to a pint of water. 

It is made very plain to them that vomiting or a green undigested 
stool is a danger-signal which always means that the milk must be 
withheld for twenty-four hours or longer whether the child is nursed 
or bottle-fed, and that either barley-water or one of the other carbo- 
hydrate gruels (page 125) must be substituted until such time as 
the stools improve or the vomiting ceases. This is one of the most 
important life-saving measures the physician can teach the mother. 
An immense majority of the intestinal diseases of summer which 
destroy thousands of lives yearly, have their origin in a neglected 
acute indigestion and diarrhea, which if properly managed means a 
slight illness of but a day or two. Therefore it is further impressed 
upon the mothers that upon resuming the milk diet, it must be given 
at first greatly reduced in strength and then gradually increased 

509 



5IO INSTRUCTIONS FOR THE) SUMMEjR 

until food of the previous strength is given. Beginning with one-half 
ounce of skimmed milk in each feeding, by watching its effects upon 
the temperature and the stools, an increase of perhaps one-half ounce 
may be made each day. 

I have experienced not a little trouble in the past in securing safe 
milk for infants who were removed at a considerable distance from 
the depots of the better class of dairies that supply certified milk. 
The average farmer is notoriously careless in the handling of milk, 
and in the country districts, where the milk-supply should be the best, 
it is often as bad as can well be imagined. In remote country dis- 
tricts where the milk is furnished by the farmer a special arrange- 
ment is made, by which he agrees that the cow's belly, udders, and 
teats shall be wiped off with a damp cloth before milking; that the 
milker's hands shall be washed before milking; that the few jets of 
the fore-milk shall be thrown away ; and that as soon as the milk is 
drawn it shall be strained through absorbent cotton into a quart 
milk bottle, suitably corked, and placed in a pail of cracked ice. A 
mother of one of my patients is using her silver champagne-cooler 
for this purpose at the present time! The cracked ice and the ab- 
sorbent cotton are, of course, furnished by the consumer. For the 
extra trouble the farmer receives from twelve to twenty cents a 
quart for the milk. At one resort three babies were supplied in this 
way by one small producer, with a comparatively safe milk. The 
improved milk-pail (Figs. lo, ii) insures a much cleaner milk, as it 
offers much less opportunity for droppings to fall into it during the 
milking. 

For those who have country homes and who can control their 
milk-supply the above precautions may be carried out to the letter. 
By such careful control of the home product, and by the use of milk 
from those dairies only which observe the above precautions, the acute 
digestive disorders of summer among my patients are rendered a very 
unusual occurrence. These precautions, with the knowledge of the 
mother or nurse as to what to do at the first sign of a digestive dis- 
order, will reduce the number of the so-called summer diarrhea cases 
to a very insignificant figure. 

Among out-patients in large cities who have to use other milk 
and milk less clean, summer diarrhea must prevail. Among these, 
however, the death-rate may be remarkably reduced through the 
education of the mothers. At the out-patient department at the 
Babies' Hospital there is a very low death-rate from summer diar- 
rhea. At this dispensary there is a clientele of fairly intelligent 
mothers who have been coming to us for years. By pamphlets 
of instructions as given below, and by showing these mothers 
that we have a personal interest in their children, we gain their con- 
fidence. They believe what we tell them, and, as a result, we re- 
peatedly have children brought to us v>rell along the road to recovery. 



INSTRUCTIONS FOR THK SUMMKR 5 II 

For example, a child had developed diarrhea; he had been given 
a dose of castor oil, his milk was stopped and barley-water or rice- 
water given. The mothers are further told that it is never a good 
thing for a baby to have diarrhea ; that a diarrhea is never without 
dangers ; and that an infant who has frequent attacks of indigestion 
during the cooler months is very sure to develop diarrhea during the 
hot months ; and that the safest means of keeping a baby well in the 
summer is to keep him well all the year round. 

RuivKS FOR THE) 

CARE OF DISPENSARY INFANTS AND YOUNG CHILDREN 
During the Summer. 

1. Clothing: During the very hot days the baby should wear a 
napkin, a thin gauze shirt, and a thin muslin slip; an abdominal 
binder made of thin material, and loosely applied, maybe worn until 
the child is six months of age. After this age the binder is not nec- 
essary. 

2. Bathing: Every child should have one tub-bath daily. On 
very warm days from two to four ten-minute spongings with cool soda 
water (one teaspoonful of bicarbonate of soda to a pint of water) 
will greatly add to the child's comfort. 

3. Fresh Air: Fresh air is of vital importance. Leave the win- 
dows open. Keep the child in the open air when possible. Avoid 
the sun. Select the shady side of the street and the shade in the 
parks. 

4. Sleep: Sleep is very necessary for growing children. A noon- 
day nap of at least two hours should be insisted upon until the child 
is four years of age. 

5. Soiled Napkins: Soiled napkins should be placed in some cov- 
ered receptacle containing water, and washed at the earliest oppor- 
tunity. 

6. Drinking-water: Boil one quart of w^ater every morning. Put 
it into a clean bottle. Keep the bottle in a cool place. Give the 
water between the feedings, as much as the child will take. 

7. Breast-feeding: The mother should wash the nipple with plain 
cold water before each nursing. She should be very careful as to 
diet and the habits of life. The bowels should move once a day. 
Constipation in the mother produces illness in the child. There 
should be three plain, well-cooked meals daily, consisting largely of 
milk, meat, vegetables, and cereals. Beer and tea are often harmful. 
A large quantity, a couple of pints or more daily of either, is positively 
dangerous. 

From birth to the third month: The baby should be nursed at two 
and one-quarter hour intervals during the day. Nine nursings in 



512 INSTRUCTIONS FOR THE SUMMER 

twenty-four hours, with only one nursing between 10.30 p. m. and 

6 A. M. 

Third to sixth month: The nursings should be at three-hour intervals 
during the day ; seven to eight nursings in twenty-four hours, with one 
night nursing. 

Sixth to ninth month: The child now takes a larger quantity at 
each feeding and the night nursing is not necessary. He should be 
nursed at three to three and one-half hour intervals ; six nursings in 
twenty-four hours. 

Ninth to twelfth month: The nursings should be at three and one- 
half to four-hour intervals, five nursings in twenty-four hours. 

8. Bottle-feeding: The bottle should be thoroughly cleansed with 
borax and hot water (one teaspoonful of borax to a pint of water) 
and boiled before using. The nipple should be turned inside out, 
scrubbed with a brush, using hot borax water. The brush should 
be used for no other purpose. There should be three or four sets of 
bottles and nipples. The bottles and nipples should rest in plain 
boiled water until wanted. Never use grocery milk. Use only 
bottled milk which is delivered every morning. The milk should be 
boiled for five minutes immediately after receiving. The feeding 
hours are the same as in breast-feeding. Children of the same age 
vary greatly as to the strength and amount of food required. A 
mixture, when prepared, should be poured into a covered glass fruit- 
jar and kept on the ice. For the average baby the following mix- 
tures will be found useful : 

For a child under three months of age: Nine ounces of milk, twenty- 
seven ounces of boiled water, four teaspoonfuls of granulated sugar. 
Feed from two to four ounces at two and one-quarter-hour intervals- 
nine feedings in twenty-four hours. 

Third to sixth month: Eighteen ounces of milk, thirty ounces of 
barley-water, six teaspoonfuls of sugar. Feed four to six ounces at 
three-hour intervals— seven feedings in twenty-four hours. 

The barley-water is prepared by boiling a tablespoonful of Rob- 
inson's barley flour or Cereo Co.'s barley flour in one pint of water for 
twenty minutes ; strain and add water to make one pint. 

Sixth to ninth month: Twenty-four ounces of milk, twenty-four 
ounces of barley-water, six teaspoonfuls of granulated sugar. Feed six 
to eight ounces at three-hour intervals — six feedings in twenty-four 
hours. 

Ninth to twelfth month: Thirty-eight ounces of milk, twelve ounces 
of barley-water, six teaspoonfuls of granulated sugar. Feed seven to 
nine ounces at three and one-half hour intervals — five feedings in 
twenty-four hours. 

9. Condensed Milk: When the mother cannot afford to buy bot- 
tled milk, when she has no ice-chest or cannot afford to buy ice, she 
should not attempt cow's-milk feeding, but canned condensed milk 



SUMMER RESORTS 5 13 

may be used as a substitute during the hot months only. The can, 
when opened, should be kept in the coolest place in the apartment, 
carefully wrapped in clean white paper. The feeding hours are the 
same as for fresh cow's milk. 

Under three months of age: One-half to one teaspoonful condensed 
milk; barley-water No. i (see formulary, page 129), two to four 
ounces. 

Third to sixth month: Condensed milk, one to two teaspoonf uls ; 
barley-water, four to six ounces. 

Sixth to nhith month: Condensed milk, two to three teaspoonf uls ; 
barley-water, six to eight ounces. 

Ninth to twelfth month: Condensed milk, three teaspoonf uls ; 
barley-water, eight to nine ounces. 

10. Feeding after one year of age: All children should be weaned 
at the age of twelve months unless otherwise ordered by a physician. 
The bottle-fed, also, at this age require more than milk and cereal 
water. During the second year children are almost invariably badly 
fed. 

Four meals a day should be given at the same hours every day. 
The mother will select suitable meals from the following articles: 
soft-boiled &gg\ scraped rare beef; strained broth of beef, mutton, 
or chicken with stale bread broken into it; toast and butter; stale 
bread and butter; toast and milk; stale bread and milk; oatmeal 
(cooked three hours) and milk; hominy (cooked three hours) and 
milk; cornmeal (cooked two hours) and milk; farina (cooked one 
hour) and milk. The milk used must be boiled, during the hot 
weather. 

11. Summer Diarrhea: When the baby has loose green passages 
it means that he is sick and needs medical attention. The disease is 
frequently mild at the beginning. There may be no fever and the 
child may show no signs of illness other than the diarrhea. Such a 
baby oftentimes, with milk-feeding continued, becomes dangerously, 
if not fatally, ill in a very few hours. The simplest cases of vomit- 
ing and diarrhea during the summer must never be neglected. A 
baby sick in this way should be given two teaspoonfuls of castor oil. 
Stop the milk at once. Give only barley-water or rice-water until 
the child can be taken to the family physician or to a dispensary. 
With slight variations the above rules may be made to apply to many 
outside of the dispensary class. 

SUMMER RESORTS 

Where to take a baby for the hot months of the year is a vexed 

question which is raised in many city households every year, and it 

is one concerning which the physician is frequently called upon for 

advice. Several years of observation of a great many New York 

33 



514 INSTRUCTIONS I^OR THE SUMMER 

City children who have spent the summer out of town have led me 
to the following conclusions : 

First, the most desirable summer outing is the first half of the 
season at the seashore, the remainder inland, preferably in the moun- 
tains. 

Second, the next place in order of desirability is inland, preferably 
the mountains, for the entire summer. 

Third, the least desirable is the seashore for the entire summer. 

It is not to be understood that many children will not do well 
if kept at the seashore throughout the hot months. Some, indeed, 
improve most satisfactorily, but among my own patients I have re- 
peatedly been impressed with the disadvantages of a too prolonged 
stay at the seashore. If kept there during August, infants are apt 
to show signs of lassitude, and while not ill, they do not return to the 
city in the autumn with the vigor, appetite, and general robustness 
which characterize those from the hills and mountains. It must be 
remembered that only New York city children are referred to. Chil- 
dren whose home is a seaport thrive best when given the benefit of 
a complete change to the dry, invigorating air inland. Children with 
catarrhal tendencies, bronchitis, adenoids, before or following opera- 
tion, and children who have had attacks of rheumatism or who show 
rheumatic tendencies, should not go to the seashore, wherever their 
residence. In referring to an inland resort, the mountains, by which 
we understand an elevation of from 1 500 to 2000 feet, are not always 
necessary. The place selected, however, should be at an elevation 
of at least 600 feet. For cases of chronic bronchitis and rheumatism, 
a soil of sand or gravel is best, and the sleeping-room of the child 
should always be above the ground floor. 

Other points to be considered in connection with the summer 
outing are the kitchen facilities, which must be ample. Often the 
larger hotels refuse the right of way to the kitchen. I find that in 
this respect much more liberty is given in the smaller hotels and 
boarding-houses. The proper preparation of the child's food in the 
cramped quarters of sleeping- rooms is not impossible, but it is often 
difficult and always objectionable ; therefore if a cottage is available, 
it will be greatly to the child's advantage. Before selecting a home 
for the summer, the drainage and the source and quality of its milk- 
supply should receive the most careful attention. Country well- 
water or spring-water should invariably be boiled before using. 



THERAPEUTIC MEASURES 

COUNTER-IRRITANTS 

The counter-irritants which I have found especially useful in pedi- 
atrics are mustard, capsicum, turpentine, camphor, chloroform, and 
iodin. 

Counter-irritants are useful in children for two purposes — for the 
relief of pain and for the effect upon internal inflammation and con- 
gestion. Without doubt the diseased conditions in which counter- 
irritation is of most value are in the acute affections of the respira- 
tory tract, such as bronchitis, bronchopneumonia, and pleurisy. In 
acute bronchitis, when the terminal bronchi are involved, when there 
is cyanosis and rapid respiration — from sixty to eighty per minute — ■ 
enveloping the thorax in a mustard plaster, one part mustard to 
two of flour (see page 272), and keeping it in position until the 
skin is well reddened, will often reduce the respirations from twenty 
to thirty per minute, and the child, previously tossing and restless, 
will fall asleep. I have repeatedly been asked by nurses and mothers 
if the counter-irritation could not be appHed more frequently because 
of the apparent relief experienced by the patient. The applications 
may often be made with advantage at interA^als of from four to six 
hours. They should be sufficiently strong to produce the desired red- 
ness of the skin in from five to ten minutes. This will usually be 
produced by using one part of mustard to tw^o of flour, when the 
appHcations are first used. When the skin becomes tender from 
the repeated applications, but one part of mustard to five or six of 
the flour may be required. If the plaster is made too weak, it must 
remain long in contact with the skin, which thereby becomes macer- 
ated. 

Indications. — In Acute Inflammations of the Respiratory Tract. — 
When the bronchitis is of the asthmatic type, when there is decided 
bronchial spasm associated with bronchial catarrh, the counter- 
irritation furnishes not a little relief. In this condition the whole 
thorax should be enveloped. In bronchopneumonia with consid- 
erable bronchitis, local applications of mustard over the involved 
areas are to be advised. The pain from pleuritic inflammation oc- 
curring independently of or at the onset of lobar pneumonia, or 
when it develops during bronchopneumonia, may be considerably 
relieved by counter-irritation. Here also the mustard should be 
used only over the painful area. When the pain is severe, equal parts 
of mustard and flour may be used for the first application, if carefully 

515 



5l6 THE^RAPKUTIC MEASURES 

watched, for a quick, sharp skin reaction should be produced. If 
there is any further action than that of a sedative through retarding 
the inflammatory process within, we have no means of proving it. 
The mother or nurse should always be cautioned to watch the skin 
under a counter-irritant so that a blister shall not be produced. 

During the stage of engorgement and congestion of the bronchi, 
indicated by roughened or sonorous breathing with occasional sibilant 
rales, a brisk counter-irritation with mustard, or with camphorated 
oil and turpentine, appears to hasten the progress of the case toward 
recovery. That a respiratory disease is ever aborted by these 
methods, as claimed by some, is exceedingly doubtful. If the tur- 
pentine is used with the camphorated oil, the proportion should be 
one part of turpentine to two parts of the camphorated oil. The 
mixture should be well shaken before use and applied with the hand 
vigorously for ten minutes or until a distinct redness of the skin is 
produced. The mustard or the turpentine should be used in these 
cases at least three times a day. I know of no condition where it is 
necessary to blister a child's skin. Capsicum vaselin may be used 
in the same way and for the same purpose as the camphorated oil 
and turpentine. 

In Colic. — In severe colic a turpentine stupe will often furnish 
prompt relief, twenty drops of turpentine being mixed with one pint 
of water at io6° F. Into this a piece of flannel is dipped and wrung 
sufliciently dry not to moisten the bed-clothing and placed over the 
abdomen. Over this is placed a dry flannel and oiled silk so as to 
retain the heat and moisture. The application may be renewed 
every fifteen or twenty minutes if necessary. 

In Pleurisy and Empyema. — ^When adhesions exist in empyema 
and pleurisy, while the pain is not acute, there is an uncomfortable 
drawing, dragging sensation in the chest which may persist for 
months. This has been relieved in a few of my cases by the tincture 
of iodin, U. S. P., painted over the painful parts every third or fourth 
night. 

In Intercostal Neuralgia. — In intercostal neuralgia, not infre- 
quently seen in overworked school-girls, the repeated application at 
intervals of three or four days of tincture of iodin over the point of 
exit of the involved nerve, will often be followed by complete cessa- 
tion of the pain. 

Acute Articular Rheumatism. — For the pain in acute articular 
rheumatism, chloroform liniment, U. S. P., may be applied to the joint. 

ANESTHETICS 
That the use of anesthetics in children is attended with consider- 
able danger is proved by the statistics relating to the subject. That 
the greatest care and judgment should be exercised in the selection 
of an anesthetic for a child is readily understood. As a routine an- 
esthetic for the young, ether is preferable because of its safety. The 



ANKSTHKTICS 517 

popular belief that chloroform is without danger is an error and not 
sustained by statistics. There are conditions, however, when ether 
is contraindicated. In cases in which there is bronchial involvement, 
ether increases the bronchial secretions and produces a free flow of 
saliva, which is liable to be aspirated into the lungs. In case of any 
obstruction to respiration, as in laryngeal diphtheria, retropharyngeal 
abscess, and enlarged glands which may encroach upon the air- 
passages, chloroform and not ether should be employed. Ether is 
further contraindicated in scarlet fever or in nephritis. In such 
cases chloroform is to be selected. Chloroform is to be used also for 
the sake of convenience, if other conditions allow, in operations about 
the mouth and the nose. Chloroform is contraindicated in general 
weakness, exhaustion, collapse, and in anemia. Ether given by the 
drop method should be used in those cases. Statistics of chloroform 
anesthesia show^ a considerable mortality in operations for adenoids 
and enlarged tonsils. The interference with respiration and the sud- 
den hemorrhage make chloroform dangerous in these operations. In 
heart disease with imperfect compensation, any anesthetic is dan- 
gerous, but ether by the drop method is the least so. Nitrous oxid 
gas, which of late has become very popular, should be used with cau- 
tion in children under two years of age. Young children are very 
easily asph^rxiated by gas; the younger the child, the greater the 
danger. Under two years of age, sudden and alarming asph^-xia 
has resulted from its use. It should be used, therefore, very spar- 
ingly and the patient watched most carefully for signs of cyanosis. 
The use of gas in children usually precedes the administration of 
ether, as it renders the use of the latter much easier for the patient. 
It is contraindicated, however, in any condition where dyspnea 
is present; in fact, in any illness in which respiration is impeded, 
gas is dangerous. The combination of gas and ether in such cases 
is not as safe as chloroform, which is to be given in a minimum 
amount with oxygen as a safeguard. 

Danger-signals During Gas Adyninistration : 

Cyanosis; jerking respirations; dilated pupils; convulsive 
movements of any portion of the body. 

Danger-signals with Chloroform : 

Pallor; ashen color; feeble, shallow respirations, gasping in 
character; dilated pupils and separation of the eyelids; 
slow, feeble heart action. 

Danger-signals with Ether : 

Marked cyanosis; stertorous breathing; rapid pulse; dilated 
pupils; short, quick, gasping respiration. 

The use of ethyl chlorid is in the experimental stage. Statistics 
show quite a mortality from its use. In case the condition of the 
patient shows any of the danger-signals, it should temporarily or 
permanently be discontinued and some other form of anesthetic 
substituted. 



5l8 THERAPEUTIC MEASURES 



COLON FLUSHING 

In colon flushings a normal salt solution should invariably be 
used. It is given with the idea of having it retained and absorbed 
for the purpose of furnishing needed fluid to the body. It may be of 
service in any case in which but little fluid is taken by the mouth. 
It has been particularly serviceable in severe cases of scarlet fever, 
diphtheria, pneumonia, and cyclic vomiting, when little fluid was 
taken, or if taken, was not retained. The large amount of fluid 
which the colon will absorb when the organism demands it is sur- 
prising. 

In a case of cyclic vomiting, a boy, who had retained absolutely 
nothing given by mouth for three days, retained one pint at the 
first colon flushing, one-half pint more after six hours, and a sec- 
ond half -pint six hours later. The flushings were begun on the third 
day of the attack. Although the prostration was extreme, the 
prompt improvement in the general condition of this patient was 
most gratifying. After the first injection the pulse improved, the 
apathy disappeared, the child began to ask questions and showed 
interest in his surroundings. 

Severe toxic cases of diphtheria and scarlet fever, where but little 
fluid is taken and where the toxicity of the blood is extreme, as 
shown by the stupor and delirium, are often much improved by the 
free use of colon flushing, which supplies the water which the child 
needs but which cannot be given by mouth, or if given may not be 
retained. 

A boy nine years of age, ill with scarlet fever, who could take 
very little fluid, was able to retain eight ounces of a salt solution 
given at eight-hour intervals for three days. 

A child six months of age had retained absolutely nothing on the 
stomach for six days, because of intussusception. When I saw him 
on the sixth day, the respiration was superficial and slow. He was 
cold and practically pulseless. The second heart-sound could be 
heard but faintly with the stethoscope. The intussusception, greatly 
to my surprise, was reduced by water-pressure (page 223). Hot 
salt-water flushings were at once begun; the patient retained ten 
ounces, given at a temperature of 110° F., and in a few minutes there 
was a very perceptible improvement. With repeated flushings at 
six-hour intervals the child continued to improve, and made a perfect 
recovery. 

I usually order the salt solution given in quantities of from one- 
half pint to a pint, depending upon the age of the child, at intervals 
of from six to eight hours, but never at a lower temperature than 
100° F. 

The apparatus required is a small rectal tube attached to a foun- 
tain syringe. The flushing is best given with the patient resting on 



AIvCOHOIv 519 

his left side with the buttocks elevated on a pillow, the tube, well 
oiled, being introduced at least nine inches into the bowel. The 
solution is allowed to pass into the bowel, when the tube is quickly 
withdrawn. To assist in the retention of the fluid, the patient 
should remain on his side for one-half hour. 

ALCOHOL 

In its relation to children, alcohol, regardless of the form in which 
it is used, must always be considered as a drug and not as a beverage. 
It is occasionally of great service in diseases of children. Under 
certain conditions it answers better than any other means of stimu- 
lation we possess. The fact that it is grossly misused does not in any 
way detract from its value in illness. It is too often given, chiefly 
for the reason that its use, in the form of whisky and brandy and 
wine, is advocated in medical works in many of the ordinary ail- 
ments of childhood where really it is absolutely contraindicated. 
Its use, in my hands, has been that of a food and stimulant in 
very grave conditions, the duration of its usefulness being often 
completed in a day or two. When given to children for a 
prolonged period even in moderate quantities, it invariably inter- 
feres with digestion and assimilation, and therefore does harm. 
It is very liable also to act as an additional irritant to the kidneys, 
which are prone to show inflammatory changes as a result of the 
systemic toxemia, due to the disease. We have heart stimulants 
which are ordinarily as effective as alcohol and without its danger 
either to the stomach or the kidneys. 

It is my practice never to give alcohol early in an illness, unless 
the onset is accompanied by profound prostration, but rather to 
hold it in reserve until absolutely necessary. Used in this way, it 
has been of much service in two conditions in which, in my opinion, 
nothing can replace it. I refer, first, to that time which may arise 
in any grave disease when the heart fails to respond to the usual 
stimulation, as in the crisis of lobar pneumonia, and in the profound 
toxemia of scarlet fever or diphtheria. At these times the powers 
of assimilation for most drugs as well as for food are reduced to a 
minimum. When food is rejected or taken badly, when the useful- 
ness of strychnin, strophanthus, musk, camphor, and digitalis has 
been exhausted, then give alcohol, and give it in as large doses as 
may be required to produce the desired results. It is astonishing 
what large quantities of alcohol may be given without the slightest 
intoxicating effects in many such conditions. When given well 
diluted it is usually well borne and assimilated, it supports the heart, 
improves the respiration and often will carr}^ the patient through 
to a successful convalescence even when the outlook is very un- 
promising. As the system readily becomes accustomed to alcohol, 
it must be given in increasing doses. If it is begun early in the ill- 



520 THERAPEUTIC MKASURKS 

ness, it will have lost its stimulating effects by the time it is most 
needed. Brandy or whisky, well diluted, is the form in which it is 
generally used. 

The second condition in which alcohol is useful is in cases with 
greatly lowered vitality resulting from some severe illness, such as 
typhoid fever, enterocolitis, or pneumonia. With a child suffering 
from shock bordering on collapse, or when in collapse with a sub- 
normal temperature with all the vital powers at a low ebb, alcohol 
will do much to sustain him. In such cases whisky, well diluted — 
I part whisky to 6 of water — given at intervals of two or three hours, 
will hasten recovery. If the child cannot swallow, the whisky may 
be given by gavage; if vomited, double the quantity, well diluted, 
may be given by the rectum. Its hypodermic use is infrequently 
resorted to chiefly for the reason that other remedies, such as strych- 
nin and digitalis, are more effective than alcohol when so given. 
The doses vary from five drops to one-half dram every one or two 
hours, twelve to twenty-four doses in twenty-four hours, for a 
child one year of age. A child two years of age may be given one 
dram at intervals of one or two hours. Its use is attended with the 
least disturbance when it is given after the feedings. 

HEAT AS A THERAPEUTIC AGENT 

Heat has long been used as a therapeutic measure. In infants 
and children it has a wide range of usefulness, either as dry heat or 
by the use of water as a vehicle. 

Moist Heat. — Heat, water-borne, is used as follows: 

In colic and indigestion and as a diuretic, internally. 

In acute gastritis, as a sedative, by sipping it. 

In convulsions , idiopathic and uremic, by means of baths. 

In convulsions , idiopathic and uremic, as colon flushings, 105° 
to 110° F. 

In colic, as a hot stupe applied to the abdomen. 

In torticollis, as a hot compress to the neck. 

In sprains, as a hot compress to the joint or muscle. 

In acute articular rheumatism, as a hot compress to the joint. 

In retention of the urine, as a hot compress applied to the lower 
abdomen and bladder. 

In suppression of the urine {acute nephritis), as a poultice or hot 
compress over the kidneys and in colon flushings, 105° to 110° F. 

In cerebrospinal meningitis, as a hot bath or hot compress to the 
trunk and lower extremities. 

In pleurisy, as a hot compress to the painful area. 

In acute angina, as a gargle. 

In conjunctivitis, as a hot compress. 

To hasten suppuration in an abscess, as a poultice or compress. 



COLD AS A THERAPEUTIC AGENT 521 

In retropharyngeal abscess and in peritonsillitis (quinsy), as a 
throat douche. 

In earache, as a douche or by means of a hot- water bag. 

In toothache, by means of a hot-water bag, or as hot water held 
in the mouth. 

In facial neuralgia, by means of a hot-water bag. 

In prematurity, and in lowered vitality or reduced temperature 
after disease, by hot-water bags or bottles. 

Dry Heat. — Dry heat is used in the following conditions : 

In prematurity, lowered vitality, or reduced temperature after 
disease, by means of the electro therm (page 46). 

In suppression of the urine {acute nephritis), by the electro- 
therm, or by hot air (page 360). 

In using heat with children caution should be exercised as to the 
degree employed. Serious burning accidents have occurred by the 
use of hot-water bottles and hot compresses. When it is used very 
hot, the hot- water bottle should be guarded by wrapping it in flan- 
nel. Moist heat in the form of compresses, poultices, and stupes 
should always be tested by placing the vehicles against the face of 
the attendant. The adult hand will bear a greater degree of heat 
than is safe, oftentimes, to apply to the skin of an infant or young 
child. In using hot packs, hot-water bags, the electrotherm, or 
dry heat, generated by a lamp or other device, such as the Kilmer 
kettle (page 360), a thermometer should be placed between the 
child's clothing and the bed-clothing. A temperature of 110° F. is 
the highest to use with children. When water is the vehicle it must 
be remembered that the patient must be most carefully watched 
and the application frequently renewed because of the rapid evapo- 
ration. A compress or poultice must not be allowed to get cool. A 
piece of flannel or oiled silk or rubber tissue over a hot compress will 
obviate the necessity for frequent changes. 

COLD AS A THERAPEUTIC AGENT 

In the treatment of children, cold is generally used in the form 
of compresses, baths, or packs, and is indicated in the following con- 
ditions : 

In tonsillitis, acute pharyngitis, and headache, as a cold compress. 

In meningitis and pyrexia by means of the ice-bag or the cool 
coil. 

In appendicitis by means of the ice-bag. 

In endocarditis and pericarditis by means of an ice-bag. 

In fever by means of baths, cold packs, sponging, and in older 
children by colon flushings. (Not lower than 70° F. when used thus.) 

In adenitis and in threatened superficial abscess by means of an 
ice-bag. 



52 2 THERAPEUTIC MEASURES 

In hysterical and neurotic children as a spinal douche. 

In malnutrition in older children as a tonic by means of a mod- 
erate cool spinal douche following a warm bath. 

For further details as to the application of cold for special dis- 
eases the reader is referred to the discussion of the diseases in ques- 
tion. 

THE THERAPEUTIC VALUE OF CLIMATE 

That climate is a valuable therapeutic measure in the treatment 
of diseases in children is a well recognized fact. To my mind an im- 
portant advantage of a change of climate is that it means more air 
and better air. When patients go to a resort for climatic purposes 
it is usually at no inconsiderable expense, and they are therefore 
pretty likely to avail themselves of its advantages. The same 
amount of air oftentimes could be furnished at home if the family 
cooperation always could be secured. By the use of the window- 
board, the roof-garden, and the indoor airing, we can to a consider- 
able degree make a climate of our own. Nevertheless, in the ma- 
jority of families the open-air treatment cannot be carried out suc- 
cessfully; therefore the best interests of the patients are secured 
when they are sent away from home. There are conditions also in 
which such means as those just mentioned do not apply even if they 
are carried out. We can give children warm air, and regulate the 
temperature of the air in the winter ; but, if they live in any of our 
coast towns or villages, we cannot give them cool, dry air in summer. 
Children who can be removed from a large city to the country, in- 
land, for the summer, are invariably benefited, not only as regards 
their food capacity and the ordinary influences of open-air life, but 
they acquire also greater powers of resistance, and are thus less Hable 
to attacks from acute intestinal diseases. (See Summer Resorts, 
page 513). 

During the colder months New York city children who are con- 
valescing from pneumonia, pertussis, or any prolonged illness which 
has greatly reduced them, will make a much more rapid recovery 
when removed to Lakewood or Atlantic City, where open-air life 
is more easily secured than at home. Infants and children suffering 
from chronic digestive disorders, marasmus, and malnutrition, who 
are given the advantages of climate or open-air methods either in the 
home (page 153) or by a change of residence, invariably make a more 
rapid recovery than do those deprived of it because of a lack of appre- 
ciation of its value, or through fear of the child's taking cold. 

Again, there are diseases in children in which the sudden change 
of temperature, affecting the peripheral circulation, may be decidedly 
harmful. Such conditions exist in slow convalescence from acute 
nephritis, and also in chronic nephritis. 'These cases require an 
equable climate, with a permissible outdoor Hfe such as is furnished 
during our colder months by Florida and Lower California. 



PROMISCUOUS USE OF DRUGS BY THE FAMILY 523 

My experiences as to the effects of climate in asthma have been 
contradictory. As a rule, cold climates and high altitudes such as 
are offered by the Adirondacks, increase the asthma, particularly if 
emphysema is also present. Nevertheless, I have seen patients who 
were comfortable only when living under such climatic conditions. 
From November ist to May ist the best results have been effected 
in children by a change of residence from the cold and changeable 
weather of the Middle and Eastern States to Lower California or 
Florida. Residence at the seashore has not been helpful to my pa- 
tients. Older children whose parents can afford it should be sent to 
a boarding-school, or to some other institution of learning located 
where the climate is such as to guarantee freedom from attacks. 

The best winter climate for a child with pulmonary tuberculosis 
is a dry climate with a mild temperature, neither high nor low, but 
with sunshine in such abundance as to permit a daily outdoor life. 
Such a cUmate is found in southern New Mexico and Arizona. These 
places furnish conditions as near to the ideal as it is possible to 
approach. The Adirondacks, while furnishing a climate in winter 
which may be too severe for young children, answers well for those 
from eight to nine years of age in whom the disease is not far ad- 
vanced. 

The sanitarium treatment is always advised if the patient can 
afford it. Its advantages rest in the fact of the discipline, the diet, 
the amount of exercise, the sleeping quarters, the clothing — in short, 
in all the details of life, every one of which is important. In a sani- 
tarium all these matters are in the hands of those who are skilled in 
the management of the disease, and who direct each case according 
to its individual needs. Resorts for tuberculosis cases are dangerous 
because of the possibilities of reinfection through the carelessness of 
others. In a well-managed sanitarium, however, regulations regard- 
ing expectoration and the care of the sputum reduce this danger to a 
minimum. Sanitariums, however, are available to but few patients. 
Many have not the means necessary to a change of residence, and 
many others refuse to allow their children to be separated from 
them, both of which facts necessitate the home treatment of a great 
majority of the cases of pulmonary tuberculosis in young children in 
our larger cities. (See page 300.) 

PROMISCUOUS USE OF DRUGS BY THE FAMILY 
While the giving of drugs to children by members of the family 
is not to be encouraged, I find it wise to furnish to most mothers a 
list of "permissibles." The love of people all the world over for 
drugs and their faith in their efficacy is so great that if they are not 
supplied by the physician, they are very apt to secure them elsewhere. 
If the reader has had an opportunity to look through the closets or 
chests of his patients, where medicines are kept, he perhaps has been 



524 THKRAPKUTIC MKASURKS 

surprised at the number of preparations of proprietary and patent 
medicines which met his gaze. The solution of the so-called "nos- 
trum evil" would be very simple if every physician would take the 
trouble to explain to his patients the character of — or, better, send 
them a copy of the official analyses of— the various proprietary drug 
preparations on the market. They should be convinced not only 
of their worthlessness, but also of the dangers attending their use. 
If mothers knew that most cough syrups and colic cures contain opium 
or some of its derivatives, they would not give them to their children. 
Neither would they themselves take the various tonics and restora- 
tives, "discoveries," and "bitters" in the market if they knew that 
they contained a large percentage of alcohol. It is the duty of phy- 
sicians to counteract, by teaching, the influence of the ingeniously 
constructed medical advertisements in the daily and weekly press, 
in both religious and lay periodicals. Not a little of what passes for 
knowledge of diseases and their so-called treatment is thus obtained 
by the layman through means that are intentionally misleading. It 
has long been my custom to give the mother prescriptions for coughs, 
for head colds, and for constipation. They are prepared and kept 
on hand for use in case they are required. At the same time the 
mother understands that I am to be called at once as soon as the 
child has fever. In defense of this practice, which may be open to 
criticism, I would state that I prefer to have my young patients take 
the remedies I prescribe, and which are harmless, rather than to have 
them run the risk of the administration of opium and alcohol, which 
would be very apt to be the case if this precaution were not taken. 

UNPALATABLE AND NAUSEATING DRUGS 
It is impossible to mention in detail all the drugs which might be 
included under this heading. Only those will be referred to which 
we are obliged to use almost daily in our work — drugs which are 
either unpleasant to the taste or which may be badly borne by the 
stomach or drugs combining both these elements. How to admin- 
ister certain drugs so that their use may be continued and yet not 
interfere with the digestive function, is a question which deeply con- 
cerns those who may have children for their patients. The element 
of taste is a most important one in a child; therefore, when possible, 
drugs disagreeable to the taste should be given to children in tablet 
or pill form or in capsule. The continued use of a drug oftentimes 
depends upon its being made palatable. As a general rule, when 
pills, tablets, or capsules are given, one-half glass of water should be 
taken at the same time, in order to diminish any possible irritant 
effects upon the mucous membrane of the stomach. 

Salicylate of Soda. — Salicylate of soda is a drug disagreeable in 
taste and very Hable to destroy the appetite and interfere with di- 
gestion. In acute rheumatism its use is invaluable, and we are 



UNPALATABLE AND NAUSEATING DRUGS 525 

obliged oftentimes to give it in large doses. It is best given after 
meals with one-half glass of milk. It is better to give fairly large 
doses at this time, well diluted, rather than more frequent smaller 
doses. It usually is better borne if given in solution with pepper- 
mint-w^ater or with simple ehxir diluted 50 percent with water; but 
the taste when thus given is only partially disguised, and being still 
very objectionable to many, it may be given in capsule if the patient 
is old enough, care being taken to give a considerable amount of water 
or milk with each capsule. 

lodid of Potash. — This drug is indispensable and is one for which 
no other can be substituted. It is best given in solution. It is most 
disagreeable in taste and a direct irritant to the mucous membrane 
of the stomach. Like salicylate of soda, it should be given after 
meals with from one-half to one glass of water or milk. It is best 
given plain, using the saturated solution, which may be dropped into 
the milk. 

Bichlorid of Mercury. — This drug is usually given in such small 
doses that its irritant properties are but little felt. It is best pre- 
scribed in tablet form, dissolved in two teaspoonfuls of water and 
followed by a swallow of water. When possible, it should be given 
after feeding. 

Alcohol. — Alcohol is another drug which should be given well di- 
luted, regardless of the form in which it is administered. It is best 
given with or after food, but it should always be given diluted with 
at least six parts of water, if whisky or brandy is used. 

Ipecac and Tartar Emetic. — Ipecac and tartar emetic, when em- 
ployed as expectorants, are best given with sugar of milk in powder 
or tablet form. They should never be given on an empty stomach. 
Two or three teaspoonfuls of water should precede their adminis- 
tration when they are not given within a reasonable time after 
feeding. In many children, when given without this precaution 
even in the usual doses, they will often decrease the appetite and the 
digestive capacity. 

The Ammonium Salts. — Carbonate of ammonia must always be 
given in solution and should always be well diluted with water. Mu- 
riate of ammonia may be used in tablet or powder form. Water or 
milk should precede the administration of either. One part of 
simple elixir with two parts of water make an agreeable combination. 

Oils. — Oils used for nutritive purposes should invariably be given 
after meals. Plain cod-liver oil or any of the preparations contain- 
ing it should never be given on an empty stomach. 

Castor Oil. — Castor oil is best given when the stomach is empty. 
A much more prompt and satisfactory cathartic effect is produced 
when thus given. It may be given in soda-water or coffee, with 
orange-juice or in peppermint-water. Older children sometimes 
take it better plain, sandwiched between the two halves of a pep- 



526 THERAPEUTIC MEASURES 

permint cream, first the candy, then the oil, followed by the remain- 
der of the candy. If castor oil is vomited, it may be repeated in a 
few minutes, and often will then be retained. 

Creosote. — Creosote is most difficult of administration to many 
children. I usually prescribe the carbonate, which is ordered to be 
dropped into one or two teaspoonfuls of wine after meals. It may 
also be given in soft capsules, or in an emulsion. 

Quinin. — Quinin should be given in solution or in capsule. Quinin 
pills as they are sometimes made, with an insoluble coating, pass un- 
changed through the entire intestinal canal. When given in solu- 
tion, a most satisfactory menstruum is a preparation of yerba santa, 
known to the trade as yerbarzine (Lilly). The bisulphate should 
always be prescribed for children, for the reason that it may be given 
in complete solution without the addition of acid. 

Strychnin. — Strychnin on account of its taste is often strenuously 
objected to, and is therefore better given in tablet triturate form. 
If the tablet cannot be swallowed, it may be broken into small pieces 
(not powdered) and mixed with a teaspoonful of orange pulp or in a 
thick cereal jelly. 

Digitalis. — Digitalis, when the tincture or the infusion is used, 
should never be given when the stomach is empty. It should be ad- 
ministered either after meals or follow the drinking of water or 
milk. There are few drugs that will so completely destroy a child's 
desire for food as the digitalis preparations when put into an empty 
stomach. 

Tincture of Muriate of Iron. — The tincture of muriate of iron 
should be given well diluted after meals in at least one-half glass of 
water. The child should take it through a glass tube so as not to 
injure the teeth. In the use of the iron preparations generally, they 
should be given after meals, and in case the hquid preparations are 
used, they should be well diluted with water. 



VACCINE THERAPY 

Vaccine therapy for prevention or cure of infection has for its 
object the production of an active immunity to the specific bacteria 
concerned, while serum therapy produces a passive immunity only. 

Immunity, which is resistance or lack of susceptibility to a given 
disease or microorganism, may be natural or acquired. Artificial 
or acquired immunity may be the result of an attack of the disease 
itself or it may follow inoculation with living cultures of micro- 
organisms in sublethal doses or in an attenuated state, with dead 
cultures, or with those products of the growth and metabolism of 
bacteria known as toxins. Immunity so acquired is active or 
direct, comparatively slow in appearance, and of comparatively long 
though variable duration. It is brought about by the development 
in the blood-serum of substances antagonistic to the vital activity 
of the bacteria or to the toxins. Such substances are known as 
antibodies. The serum of an animal which has been actively 
immunized and which is rich in antibodies may be inoculated into 
another animal for the purpose of combating infection. The immu- 
nity thus produced in the second animal is indirect or passive and 
of comparatively short duration. 

The antibodies are of several kinds: agglutinins, opsonins, and 
lysins. They are formed by the tissue cells under the stimulus of 
the infecting bacteria, at first locally, then generally, and are present 
in the serum and to a lesser extent in the other body fluids. The}^ 
manifest themselves in certain definite ways demonstrable and 
measurable by laboratory methods : agglutination reaction, opsonic 
index, and the complement deviation test. Clinically their increase 
is accompanied b}' amelioration of the symptoms of infection. The 
aim of both vaccine and serum therapy, then, is to aid the productioii of 
antibodies in order to effect a destruction of the invading bacteria and 
the neutralization of their toxins. ]\Ietchnikoff claimed that the 
destruction of microorganisms is brought about by their ingestion 
by phagoc}^es, especially polymorphonuclear leukoc^^tes. Denys 
and lycblef proved that there is a substance in the blood-serum which 
prepares the bacteria for phagocytosis. This sensitizing substance 
was named " opsonin " by Wright and Douglas, who elaborated 
methods for its study in the laboratory and for its practical apph- 
cation to the treatment of infections by means of vaccines made of 
suspensions of dead bacteria. 

It has been found in general th^-t the opsonins are below normal 

527 



528 VACCINE THERAPY 

at the onset of an infection and during the height of the acute stage, 
and that, as improvement occurs, the amount of opsonin in the blood- 
serum increases. The administration of dead cultures of the bac- 
teria causing the infection stimulates the production of opsonins, 
as proved by improvement in the symptoms and rise in the opsonic 
index. 

Technic. — In order to estimate the opsonic index it is necessary 
to prepare serum from the patient, serum from a normal person, 
leukocytes from a normal person, and a culture of the bacteria from 
the patient's lesion. 

Serum is readily obtained by pricking the finger and catching 
the blood in a small curved glass tube, as recommended by Wright. 
The blood is allowed to clot in the tube, and the resulting clear serum 
is removed by means of a capillary pipet, which is then sealed at 
its narrow end. The test should be made as soon as possible after 
drawing the blood, preferably within twenty-four hours. 

Leukocytes are obtained from ten drops of normal blood caught 
in a tube containing ten cubic centimeters of 1.5 percent sodium 
citrate in normal salt solution. The mixture is centrifuged and the 
fluid carefully drawn off and replaced by normal salt solution, in 
order to wash the blood-cells free from serum. After centrifuging 
again, the supernatant fluid is removed and the upper layer of white 
blood -cells taken up into a capillary pipet, whose lower end is then 
sealed in the flame. This is known as the "leukocytic cream." 

The suspension of bacteria is made in normal salt solution from 
an agar-culture not over twenty-four hours old. It must not be too 
thick and should be free from clumps. 

Capillary pipets of similar caliber having been selected, equal 
quantities of patient's serum, leukocytes, and bacteria are drawn 
up and thoroughly mixed in one, while normal serum, leukocytes, 
and bacteria are drawn into another. A control, using normal salt 
solution instead of serum, should also be made. The pipets are 
sealed below and incubated for fifteen minutes at 37° C. The 
mixture is then expelled on a glass slide, thoroughly mixed again, 
and spread on clean slides. After fixing in methyl alcohol and 
staining in methylene blue the slides are placed under the microscope 
and the number of bacteria contained within fifty leukocytes is 
counted. This gives the phagocytic index, and the quotient of the 
patient's and the normal phagocytic indices equals the opsonic 
index of the patient. More satisfactory results have recently been 
obtained by making the tests with diluted serum, according to 
Neufeld. The opsonins in the normal blood-serum used for control 
are found to disappear in a lower dilution than do the immune 
opsonins in the blood of the patient who has been immunized by the 
disease or by the administration of vaccines. 

The vaccine is made by suspending agar-cultures less than 



STAPHYLOCOCCUS INFECTIONS 529 

twenty-four hours old in normal salt solution. Equal quantities 
of bacterial suspension and of blood from a normal person are drawn 
into a capillary pipet, mixed, and thinly spread on a slide. The 
red cells and the bacteria are then counted in a number of fields. 
Since the normal blood contains five million red cells to the cubic 
millimeter, the number of bacteria in proportion to the red cells can 
be estimated per cubic millimeter, and the actual count per cubic 
centimeter readily calculated. The tube containing the bacterial 
suspension is sealed and heated for two hours at 60° F. Control 
cultures are then made to test the sterility of the undiluted suspen- 
sion. This having been properly accomplished, the vaccine is 
diluted in bottles of sterile normal salt solution sealed with a rubber 
cap and paraffin, according to the dose desired per cubic centimeter. 
Thus, if the actual count showed that five thousand million bacteria 
were present in a cubic centimeter, diluting the vaccine fifty times 
by adding one cubic centimeter of undiluted vaccine to forty-nine 
cubic centimeters of sterile salt solution would make a vaccine 
containing one hundred million bacteria in one cubic centimeter. 
Injections of one cubic centimeter or less are made into the shoulder, 
back, or thigh under strictest aseptic precautions. 

Staphylococcus Infections. — It is in these cases that the 
vaccine treatment has given the best results. While it is always 
wise to use a vaccine prepared from the patient's own strain of 
staphylococcus, it is not absolutely essential that this be done. 
Any stock vaccine which has given good results in a similar case 
may be used, provided that it has been proved by a culture made 
from the pus of the patient's lesion that staphylococci are the causa- 
tive factors. It is essential also to know whether the staphylococcus 
aureus or albus be present, in order that the appropriate vaccine 
may be employed. The dose in infants under one year should vary 
from seven to fifteen millions of dead cocci, and in infants between 
one and two years fifteen to twenty millions may be given. In 
children over. three years of age twenty to fifty millions may be used. 
The inoculations are repeated on the sixth to the tenth day if neces- 
sary. When the opsonic index is estimated throughout the vaccine 
treatment of such a case, it is observed that a slight fall in the index 
follows the injection and that it may be accompanied clinically by 
a slight feeling of malaise, but no rise of temperature should occur. 
This constitutes Wright's negative phase of the reaction of immunity, 
and is followed in one to several hours by a rise in the index and 
improvement in the clinical s^^mptoms. As soon as the opsonic 
index begins to fall below the normal on the fifth to the tenth day, 
another injection is indicated. As a ^natter of fact, the test for the 
opsonic index has been found to he too uncertain to make it practical 
and worth while to follow systematically, the clinical symptoms being 
sufficient indication of the value of the vaccines. Too rapid or too 
34 



530 VACCINE THERAPY 

large dosage must be avoided, because there is danger of exhausting 
the responding power of the human organism by overstimulation. 
The temperature should be taken before the vaccine is injected, and 
every three hours during the following twenty-four. 

Furunculosis in young infants has proved readily amenable 
to treatment by staphylococcus vaccines. Improvement is shown 
by a much more rapid healing of the furuncles already incised and 
by the non-appearance of new ones. After the second inoculation 
improvement is the rule. The amount of pus is lessened and fewer 
dressings are required in cases so treated. No bad effects from the 
injections have been noted. It is best to begin with a small dose 
and increase if necessary. 

In acne excellent results have been obtained by some observers; 
others report negative results. Larger doses are usually necessary. 

In otitis media of staphylococcus origin, vaccines are reported., 
evidently by enthusiasts, as having proved of value, as also in suppu- 
ration in the antnim, in styes, in osteomyelitis , and in empyema. It is 
claimed in the latter disease that operation may, in rare and favorable 
cases, be obviated by the vaccine injections. After operation the 
vaccine is said to be of service in aiding the more rapid disappearance 
of pus from the pleural cavity and hastening the healing of the 
wound. 

Any local suppuration due to staphylococci is benefited rapidly 
by vaccine administration. In general septicemia the results have 
been encouraging (Wright). 

Streptococcus Infections.^In all cases of streptococcus in- 
flammations the results of vaccine therapy have been far less 
brilliant than in staphylococcus cases, but still encouraging enough 
to warrant their further use. It seems to be essential also, far more 
than in the staphylococcus injections, that the vaccine be prepared 
from the strain of streptococcus isolated from the patient. The 
dose is about one-third that of the staphylococcus : Two to three and 
a half millions in babies under one year of age, five to seven millions 
between one and two years, ten to thirty millions in older children. 

Erysipelas. — In erysipelas Shorer found that the course of the 
disease is apparently shortened by the inoculation of dead strepto- 
cocci, but that neither migration nor recurrence seems to be pre- 
vented. 

Scarlet Fever. — In scarlet fever the opsonic index to streptococci 
has been studied by Tunnicliff , who found that it is below the normal 
at the onset of the disease, but rises when the acute symptoms sub- 
side. As local streptococcus complications appear the index falls 
once more. Favorable results following the injections of dead 
streptococci in cases of scarlet fever have not thus far been reported. 
On the other hand, local streptococcus inflammations — adenitis, otitis 
media, and osteomyelitis — have given most encouraging results. 



GONOCOCCUS — TUBERCLE BACILLUS 531 

Gonococcus. — In vulvovaginitis due to the gonococcus in 
young infants under one year of age, the injections of dead gonococci 
have had no effect in shortening the course of the disease, in lessening 
the amount of discharge, nor in causing the cocci to disappear from 
the vagina. In older children Hamilton and Cooke found that the 
effect of the dead gonococcus injections is more marked in chronic 
than in acute cases, the disease being very decidedly shortened in 
its course. The later stages of the acute cases were also shortened, 
while no result was noted in the first weeks of the attack. Hamilton 
and Cooke observed no advantage from the use of a vaccine made 
from the patient's own organism. The initial dose of five millions 
was gradually increased to forty or fifty, according to the needs of 
the case. Injections at eight or nine day intervals proved best. 

Pneumococcus. — The few cases of pneumonia in which dead 
pneumococci have been injected showed no marked advantages 
over untreated cases. In empyema of pneumococcus origin heaUng 
has been hastened by inoculations of dead pneumococci (Ross). 

Meningococcus. — In cerebrospinal meningitis due to the me- 
ningococcus of Weichselbaum vaccine therapy has been tried, but 
it has become superfluous in view of the brilliant results obtained 
by means of the anti-meningococcus serum of Flexner and Jobling. 

Bacillus Coli Communis. — Inoculations of dead colon bacilli 
in doses of ten to fifty millions are reported to have given excellent 
results in cases of cystitis due to that microorganism. The symp- 
toms subside rapidly and the bacilli disappear from the urine in a 
comparatively short time. 

Typhoid Bacillus. — Injections of dead typhoid bacilli have been 
employed as a prophylactic measure in the English army with fair 
results. As a curative therapy in children they have not, thus far, 
been used. 

Pseudodiphtheria Bacillus. — In otitis media due to this organism 
Dr. Tunnicliff obtained apparent benefit in some cases by injecting 
the dead bacilli. The attack of otitis was postscarlatinal and acute. 

Tubercle Bacillus. — Local tuberculous lesions have been 
treated by injections of tubercuHn in very small doses with good 
effect. This is true of chronic local tuberculosis without constitu- 
tional symptoms, especially in bone, joint, gland, skin, and eye 
affections. In pulmonary phthisis of a chronic type, running a 
nearly apyretic course, tuberculin is also of value. In all acute 
tuberculous lesions with marked fever and general symptoms tuber- 
culin therapy has proved useless and it may be attended by grave 
danger. The dose of crude tuberculin^ administered for purposes 
of immunization in a chronic tuberculous lesion should be very 
small, ■3-qL_ of a milligram, gradually increased to oqVo' toVo' ^^ 
more. The inoculations should be repeated not oftener than once 

1 Koch's old tuberculin, prepared by the New York City Board of Health. 



532 VACCINE THERAPY 

in ten days, at first, and the temperature carefully measured every 
two hours. If a rise occurs, the dose has been too large, and must 
be reduced at the next injection. In selected cases of bone and 
joint disease and also in adenitis, good results have followed six or 
eight months of continued treatment, the dose being gradually 
increased in amount and the intervals shortened to three days. 
Wright maintains that the opsonic index is an essential guide to 
the regulation of the dosage. Other observers are satisfied that 
the clinical reaction is a sufiiciently accurate guide. The opsonic 
index to the tubercle bacillus is low in cases of tuberculosis, unless 
it fluctuates, due to auto-inoculation from an active lesion. It is 
the office of the treatment to permanently raise the index. 

THE NEW DIAGNOSTIC METHODS 
Tuberculin has also been used as a diagnostic measure to detect 
early, latent, or doubtful cases of tuberculosis, and it may be applied 
in three different ways : subcutaneously, cutaneously, and in the eye. 
Subcutaneous Inoculation. — The dose used for diagnosis is larger 
than that allowable for immunization purposes, from one-tenth 
to five or ten milligrams being used, according to the age of the 
child. The injection is followed in eight to twenty-four hours by 
a rise of temperature, a certain amount of malaise, tenderness at 
the seat of injection, and rales over the suspected lung area. The 
reaction is general as well as local. The temperature falls within 
twentv-four hours. No reaction occurs in non-tuberculous cases, 
while in 95 percent of tuberculosis the test is followed by a positive 
reaction. Absolute exclusion of tuberculosis, however, because of a 
negative result is not possible. The test is only applicable to cases 
which do not run a temperature over 37.7° C. (100° F.) and is useful 
in doubtful and obscure cases. It may be necessary to repeat the 
inoculations two or three times before a positive reaction occurs, 
the initial smah dose of one-tenth of a miUigram being followed in 
three days by another of one miUigram and again, if necessary, in 
three da^/s by another of three or five milHgrams in older children. 
Cutaneous Inoculation. — This method of vaccination with 
tuberculin was introduced by von Pirquet. A small superficial 
scarification is made on the forearm and a drop of undiluted tuber- 
culin is applied. An untreated scarified area of equal size is made 
at the same time for control purposes. The reaction begins within 
twenty-four hours in cases of active tuberculosis. A small red 
papule forms, surrounded by a limited area of redness and induration. 
In seven or eight days the nodule has disappeared. The control 
scarification heals without any inflammatory sign, von Pirquet 
himself uses a fine boring instrument instead of scarifying. The 
method is most valuable in infants and children under two years of 
age. A positive reaction is accepted by von Pirquet as proof positive 



THE NEW DIAGNOSTIC METHODS 533 

of tuberculosis, and a negative reaction, on the whole, means absence 
of any tuberculous focus. The exception to this rule is furnished 
by cases in the last days of a fatal mihary tuberculosis, in which the 
reaction disappears in about half the cases. If only a small focus be 
present, a second or third vaccination may be required to produce 
a positive reaction. A rapidly appearing reaction means active 
tuberculosis, while a delayed reaction means a healed or inactive 
focus. 

Ophthalmo -reaction. — This was first described by Wolff-Eisner 
and shortly afterward by Calmette, and consists of the instillation 
of one drop of one-half percent solution of tuberculin into the con- 
junctival sac of the healthy eye of the patient. Within twelve hours 
swelHng and redness are at their height, and gradually subside in 
twelve hours more. The plan in use at the Babies' Hospital, there- 
fore, is to instil the tuberculin at midnight. The reaction can then 
be studied during the entire next day. Wolff-Eisner insists emphati- 
cally that only one instillation is permissible in one eye, that a 
positive reaction means active or latent tuberculosis, and that 
failure to obtain a reaction in a clinically positive case of tuberculosis 
means error in technic and not in the method itself. The only 
exception to this rule, as in the cutaneous method, is that of cases in 
the very late stage, whose responsive power is exhausted. If no 
reaction occurs in an apparently positive tuberculous case, the 
other eye may be used for a second test. Any ophthalmic inflamma- 
tion, and especially any suspicion of eye tuberculosis, is absolute 
contraindication for the use of the method. If properly applied 
in healthy eyes no untoward results occur. 

The advantage of both the cutaneous and the ophthalmic methods 
over the subcutaneous is that they obviate the possibilit}^ of spread- 
ing the tuberculous process, since no general reaction follows their 
application. Both local methods are based upon the principle 
that in the course of a tuberculous infection all the cells of the body 
are sensitized to the products of the tubercle bacillus. When, there- 
fore, a minute quantity of such products (tuberculin) is brought 
into direct contact with a sensitized and vascular tissue like the skin 
or conjunctiva, a rapid inflammatory response occurs. 



GYMNASTIC THERAPEUTICS 

The section on Gymnastic Therapeutics is included in order to 
call the attention of general practitioners to the value of such work 
and to assist them in applying necessary treatment. Exercises are 
most often used therapeutically for children in the treatment of the 
following conditions: Flattened or narrowed thorax, kyphosis, 
scoliosis, flat-foot, congenital ataxias, and acute anterior polio- 
myelitis; also in cases of habitual constipation, malnutrition, etc. 

The following pages contain a description of the methods which 
have been carried out most successfully with my patients by Dr. 
Hugh Currie Thompson, New York City, to whose patience and 
skill I am indebted for the recovery of many cases, some of which 
had resisted other methods of treatment. 

The family physician has an opportunity of seeing these con- 
ditions at a much earlier stage than has the specialist, and at a 
time when they may be more easily corrected than in later life. 
When discovered, such conditions should never be neglected with 
the idea that in time the child will outgrow them. Such a belief 
is often fallacious, for unless properly treated, they are apt to become 
permanent. The necessity for the correction of physical defects 
in children is readily appreciated by parents. Certain principles 
or rules are involved in every form of practice. The following 
principles are generally applicable in gymnastic therapeutics. 

RULES 

I. Examination. — As far as possible, obtain a complete history 
of the case. Make both a general and a careful physical examina- 
tion; under the latter, note the musculature, condition of the skin, 
posture, any deviation of the spine, position of thorax and scapulae, 
side lines of body, compare length of limbs, note the condition of 
the feet. It is often advantageous to take the height and weight, 
and certain measurements, such as girth of neck, chest, and waist, 
and depth of chest and abdomen. In cases where the nervous 
system is especially involved apply the tests usually made in such 
cases. 

II. Conditions under Which Exercise Should be Taken. — (a) Tem- 
perature of Exercise-room. The temperature of the room should be 
from 68 ° to 75 ° F. , depending upon whether or not the patient is dressed. 
There should be no draft upon the patient. Therapeutic gymnastics 
involves fewer groups of muscles *than ordinary gymnastic work and 
the execution is slower. The general circulation and respiration are 
not stimulated as much and, therefore, the heat production is less. 

534 



RULES 535 

(b) Clothing. — In the beginning, the parts of the body involved 
in the exercises should be devoid of clothing. A single thickness 
of clothing may mislead as to the corrective effect obtained. At 
frequent intervals, at least once a week, the child should be uncovered 
for the purpose of observation during exercises. It is sometimes 
desirable to have the clothing removed during each treatment. 
At all times a child's clothing should be simple and hygienic, per- 
mitting unhampered movements. 

(c) Double Mirrors, etc. — The use of double mirrors and a stringed 
screen are sometimes desirable so that the child may see when he 
has a correct position. 

III. Frequency and Duration of Treatments. — Treatment should 
be for an hour daily, Sundays and holidays excepted. This is not 
too often, if the following points are considered : 

(a) The length of time during which the condition has been 
developing. 

(6) The number of waking hours intervening between treat- 
ments when faulty postures are apt to be maintained. 

(c) That progress should be made as rapidly as possible, so that 
the changed structure may be the basis for the period of growth. 

Many times this rule must be modified, owing to the physician's 
lack of time and the expense to the patient's family. From an 
hour's supervision daily it may mean supervision by the physician 
only once every two weeks, supplemented by careful home super- 
vision fifteen minutes daily. This arrangement should be the mini- 
mum of attention given to any case. 

IV. Prescription of Exercises. — (a) Forms of Exercise. — No cer- 
tain system of exercises need be followed as long as the exercises 
used have an anatomic and physiologic basis. Both active and 
passive movements are used with and without resistance. Exer- 
cises with resistance given by the physician are used much in cor- 
rective work, for in this form of exercise the physician can easily 
judge as to the amount of exertion and increase or decrease it at 
will, and the physician should remember that in most cases the 
stretching of the contracted muscles is quite as important as the 
strengthening of the weak and overstretched muscles. In cases of 
paralysis, injury, kyphosis, and scoliosis, where the weak muscles 
need treatment to restore their normal strength, the antagonistic 
muscles which are contracted and shortened should be stretched at 
every treatment (even though tenotomy has been performed) until 
the weak groups have regained their normal tone. 

(b) Accuracy of Execution. — Accuracy of execution of each and 
every exercise given in the prescription is essential. A possible ex- 
ception to this might occur in the treatment of such cases as mal- 
nutrition or constipation, where exercise per se is the essential thing, 
but even in these cases conditions may be such that very careful 
work is necessary. A prescription of exercise in itself means little. 



536 GYMNASTIC THKRAPKUTICS 

The manner in which it is executed may actually aggravate the 
condition, as the wrong muscles may be made stronger by a faulty 
manner of execution. In writing out a prescription of exercise the 
physician should be guided by the patient's capabiHty for fairly 
accurate execution of each exercise. This cannot be gauged by the 
physical examination alone, but the examination must be supple- 
mented by having the patient try the exercise for one or more days. 
Unless he can approximate the proper execution without assuming 
faulty positions or postures and without causing too much nerve and 
muscle fatigue, simpler exercises should be used. As the patient im- 
proves or becomes stronger, more difficult exercises should be given. 
In advancing, the rule regarding accuracy should be observed. 

Exercises have several details which need to be watched in order 
to secure accurate execution. At first do not confuse the child 
by requiring absolute accuracy as to every detail; rather select one 
or two of the more important ones and insist upon the most rigid 
observance of these. As the child grasps and retains these ideas 
and is able to carry them out, require more, until all are mastered. 

(d) Concentration. — Frequent repetition of the exercises is nec- 
essary to obtain desired results. In repeating an exercise many 
times, a child easily forms the habit of executing it with but little 
effort, which will soon result in inattention and carelessness. When 
this occurs bring about an increase of exertion on his part by insisting 
that every detail be mastered, or change to more difficult exercises. 

(e) Overwork. — If a child is fatigued at the end of an hour's 
rest following the treatment, he has been overworked, and the exer- 
cises should be made less difficult. A certain amount of muscle 
soreness must be expected during the first few days of work. 

(/) Rest. — In many cases the child should rest in a recumbent 
posture for half an hour after the treatment, and in nervous cases 
the treatment should be preceded by a half hour's rest. 

(g) General Health. — Attention should be given to everything 
that will build up the general health of the patient, such as bathing, 
sleep, fresh air, general exercise, diet, dress; suitable furniture (chairs, 
tables, or desks, etc.) should also be considered. Attention to these 
things will sometimes shorten the time of treatment by eliminating 
causative factors. 

V. Adaptation of Exercise to Practical Ends. — Adapt corrective 
positions to all practical ends : walking, sitting, working, or playing. 

VI. Cooperation. — Endeavor to secure the cooperation of mem- 
bers of the household, teachers or servants, between exercise periods 
in order that the progress of the child may be as rapid as possible. 
A child is not at first capable of adapting the work to practical ends 
without careful oversight of elders. 

There are two objects in treatment: One which should always 
be obtained, that of improvement; and the other, complete and 
permanent correction, which should be the aim until an insurmount- 



POSTURE AND BREATHING 



537 



able obstacle is reached. To gain these are required continuous 
and conscientious work, and the cooperation of those in charge of 
the child and of the child himself. As a rule, these objects cannot 
be obtained in a short period of time. 

After the treatment has been completed the child should be 
brought for examination every three months. 



POSTURE AND BREATHING 

Posture and breathing will first be considered, as they hold an 
important place in the correction of the conditions about to be con- 
sidered. A good posture should be maintained 
during all exercises. Between treatments the 
child should maintain as good posture as his 
condition will permit. Telling him to do this 
is not sufficient, but he should be given exer- 
cises which will strengthen the weakened and 
overstretched muscles and stretch the con- 
tracted ones, and thus enable him to assume 
an improved posture. The work for correct- 
ing posture should be taken up gradually. 
Have a child hold a good posture for short 
periods of time, beginning with one minute 
and working up to fifteen minutes. The child 
should be taught to assume and maintain a 
good posture during the entire day, no matter 
what he is doing, whether at work or play. 
In the standing posture the weight of the 
body should be brought forward until it rests 
over the balls of the feet or over a point mid- 
way between the toes and the heels. In sit- 
ting, the weight of the body should be carried 
over the posterior third of the thighs. 

For general posture, my rule consists of 
the following steps: Heels together, or ap- 
proximately so, knees w^ell stretched; chest 
raised high ; head erect with chin in (stretch 
up entire body as high as possible); poise 
weight forward over balls of feet; bring 
shoulders back and down. The feet should be 
turned outward slightly or kept straight. 
(See Fig. 62.) 

In the above rule do not relax any pre- 
vious step as a new one is taken. In sitting, 
insist that the hips be pushed well back in order 

that the child may not slide forward so as to bring the weight of the 
body over the lower spine. 

From the beginning, an attempt should be made to improve the 




Fig. 



62.— General 

URE. 



Post- 



53^ GYMNASTIC THKRAPKUTICS 

posture. Take the essentail details for the child to follow and in- 
crease the requirements as fast as practicable. These individual 
details have been tersely expressed in different ways, and one ex- 
pression may convey the idea of the detail more clearly to one patient 
and another expression to another. For instance: "Chest Up!" 
may mean that you wish the child, if he has relaxed, to take the 
best possible posture of the thorax. In taking a good position of 
the thorax, there should be no raising of the shoulders, no conscious 
taking in or holding of the breath, and the trunk should not be 
inclined backward nor the pelvis or abdomen permitted to project 
forward. 

General Considerations. — i. When children use bicycles, veloci- 
pedes, mail wagons, etc., where they propel themselves by pedal- 
ing, they should not ride with head and shoulders forward and chest 
contracted to gain advantage and leverage, but should have the 
body inclined forward from the hips, back straight, and chest ex- 
panded. 

2. Improper and insufficient diet, poor assimilation, lack of fresh 
air, and disturbed sleep cause a loss of general tone, which tends to 
make a child relax and assume bad postures. All these matters 
should receive attention. See Tardy Malnutrition, page 164. 

3. Clothing should be examined to see that it causes no pressure 
or tension. All garments should be loose and simple. The 
underclothing should be elastic and light in weight. The stock- 
ings should fit the feet and should be supported by soft elastics 
extending from V-shaped pieces at the side of the w^aist, which catch 
the stockings on the outside of the legs. The shoes should have 
flexible soles, a fairly straight line on the inside, a low broad heel, 
and should be broad enough to permit the toes to spread. So 
much depends upon the condition of the feet, both in standing and 
walking, that they should receive as careful daily attention as the 
hands. Hats should first be for protection. They should be light 
in weight and should come far enough forward to protect the eyes 
from the sun, and should never be worn far enough back to make 
the child tilt his head to balance the weight, or to make him bend 
it forward to protect his eyes from the sun. Outside wraps should 
be sufficiently light in weight and flexible enough to permit free 
movement in walking or running. 

4. Sleep. — A child should not form the habit of sleeping always 
on one side with the knees drawn up to the chest, but change from 
side to side. If the posture is very poor, he should for some time 
sleep on the back with limbs extended, and without a pillow. The 
mattress should be thin and firm, and the child's covering light in 
weight, and only a small pillow used. 

5. Furniture. — The furniture a child uses, especially his chairs, 
tables, or desks, should be adapted to his age and height. Furniture 
not properly adapted to children is one of the main causes of bad 



POSTURE AND BREATHING 



539 



posture. Chairs should have the height of seat correspond to the 
length of the lower leg. The child's feet should rest comfortably 
upon the floor, and there should be no pressure under the knee. 
The depth of the seat should be no more than the length of the 
thigh. If it is greater the child tends to slide forward, and assume 
a bad posture with the weight of the trunk over the lower spine. 
The back of a chair should not have upright spindles, but cross- 
pieces, or, at least, one cross-piece sufficiently high above the seat 
to allow the fleshy part of the hips to project underneath it in order 
to bring back the tuberosities of the ischii far enough to support the 
weight of the trunk in a good position. The lower cross-bar, pre- 
ferably adjustable, should support the back at the junction of the 




Fig. 63. — Adjustable Table, Dr. Mosher's Chairs, Board, Ladder, and Blocks for 

Ataxic Exercises. 



dorsal and lumbar vertebrae. In addition there should be another 
cross-bar to support the upper back. 

Dr. Mosher's kindergarten chair, sold by The Milton Bradley 
Company, it East i6th Street, New York city, is the best chair 
for children that has come to my attention. It is constructed in 
three sizes, with seats ten, twelve, or fourteen inches in height, but 
there is no lower cross-bar for the support of the back. If the 
seat of a chair is hollowed out, there should be no raised border at 
the back, as it would prevent the hips from being pushed w^ell back. 
If w^ell-constructed chairs cannot be obtained, ordinary chairs may 
be modified for use in the nursery or for older children, by selecting 
those having a cross-bar several inches from the seat and sawing 



540 



GYMNASTIC THERAPEUTICS 



only a slight factor 




the legs off. If the seat proves too deep, a pillow may be placed 
between the child's back and the back of the chair, but should not 
extend below the waist-line. It may be held in place by tapes. 

6. Heredity. — Parents often attribute a bad posture with flat 
chests or other physical deformities to heredity, saying that a 
child "takes after" one parent or the other. Heredity is usually 
i. e., the child may inherit a frame or general 
constitution or certain 
mental and physical 
characteristics resem- 
bling those of a parent, 
but the faulty posture, 
flat chest, etc., are in 
most, if not all, cases 
acquired. A well-nour- 
ished infant has a 
straight back. In a 
well child, you seldom 
see a flat chest before 
the age of three years. 
7. In very young 
children, the deformity 
is often induced by the 
position assumed in 
pla}^ For instance, the 
sitting position on floor 
or bed with legs ex- 
tended and spine bent 
forward, which most 
young children assume 
in playing, keeps the 
chest in a bad position 
for long periods of time 
day after day. This is 
especially true if, for 
any reason, the back 
muscles are not as 
strong as usual and can- 
not easily maintain the 
weight of the trunk in 
an erect position. For 
children who are kept in bed when not seriously ill, a folded blanket 
or air-cushion may be used as a seat, and a bed table or tray, for 
playthings and meals. A support may be used for the back if needed. 
Fig. 63 shows Dr. Mosher's chair and an adjustable table, which 
may be made for use in the nursery. The top of the table, 2 J by 





Fig. 64. — Posture Exercise. 
Chest raising against a flat perpendicular surface 



POSTURK AND BREATHING 



541 



4 feet (or 3 by 5), is made of well-seasoned boards h inch in thick- 
ness. These boards are held together by quarter-inch pegs and 
holes, as are the leaves of an extension dining-table. Two sets of 
light-weight wooden horses (legs f by 2 inches and cross-pieces i 
by 2 J inches) are used for supports: one set, for use when the child 
is seated, 14 to 18 inches in height; the other, for use when standing, 
24 to 30 inches in height. If desired, the whole may be painted 
white or stained and varnished. For reading there should be a 
book-support for the child's books, so that he may keep his head 
erect. 

8. School Hygiene. — Physicians as well as parents should interest 
themselves in school conditions, as often it is in school that the child 




Fig. 65.— Posture Exercise. 
Arching body. 

contracts bad postures, because of the long hours of confinement, 
unsuitable desks and seats, and frequently by a lack of proper 
ventilation. 

Exercises. — The following exercises may be used for correcting 
bad posture: 

1. The child stands with toes from 2 to 4 inches from a flat per- 
pendicular surface, as a closed door. Let him assume a good stand- 
ing position ; sway the body forward from the heels (heels kept on 
floor) until the chest touches the door; but neither the abdomen 
nor head should touch it. (See Fig. 64.) 

2. Raise arms sideways to shoulder height; lift heels; stretch 
up with head and chest, in with chin, and out with arms. 



542 GYMNASTIC THKRAPKUTICS 

3. The child lies on his back on a fairly hard, flat surface. Place 
your hands under his head, raising it an inch or two. He then, 
reclining as before, arches his body from head to heels. (See Fig. 
65.) The knees should be kept straight. In the beginning, as 
in figure, he may aid himself with his hands in arching body. 
Later the arms should be folded lightly on the chest. 

4. The child standing, should raise arms sideways, turn palms 
up at shoulder-height, and continue to raise them until the hands 
are midway between horizontal and vertical; sway body forward; 
stretch up with chest and head, in with chin, and out and up with 
finger-tips. 

5. Clasp hands, back of head. Raise chest well and press head 
backward, chin in, resisting with hands. Keep elbows well back. 

Walking Movements. — Have patient walk on balls of feet, with arms 
extended sideways, shoulder high, maintaining a good posture. When 
capable of doing this satisfactorily, repeat with arms raised over 
head; arms should be well stretched, fingers straight, palms facing 
and separated by the breadth of the shoulders. 

Shot-bag Exercises. — A flat circular bag, 5 or 6 inches in diameter. 
The bag should hold from i to 2 pounds of shot, according to the 
strength of the child. With the child's back straight and chest 
expanded, head erect and chin close to neck, have him balance the 
shot bag on top of his head : balance while sitting or standing from 
I minute up to 30 minutes ; balance while rising from a sitting to a 
standing position from 5 to 50 times ; balance while walking forward 
and backward across the room from 5 to 20 times; balance while 
walking on the toes across the room forward and backward from 
5 to 20 times; balance the bag on the head while being read to; 
balance while taking the out-of-door walk for varying distances from 
100 feet to ^ mile; balance while running iii an easy manner. 

Following easier exercises the shot bag is also useful as an exercise 
in the treatment of chorea or ataxia when there is incoordination 
of the neck muscles. 

BREATHING 
The primary object of breathing is to aerate the blood by carry- 
ing oxygen to it by the air that enters the lungs ; secondarily, through 
the practice of deep breathing, the accessory muscles of respiration are 
developed, the breadth and depth of chest and the lung capacity 
are increased. In deep respiration the amount of air taken in 
is several times that inhaled in ordinary respiration. The amount 
inhaled in "tidal" respiration by an adult is 30 cubic inches, while 
that which can be taken in by forced inspiration is from 150 to 300 
cubic inches. Daily practice of deep breathing in the open air 
helps to increase the resistance of the lungs to diseases to which they 
are liable. 



BREATHING 543 

A mistake is sometimes made in overdeveloping the chest mus- 
cles, so that the chest becomes to a certain extent "muscle-bound," 
and the expansion is lessened, instead of increased. There is Httle 
danger of this when the development comes from taking deep inspira- 
tions rather than by muscular activity alone. While a development 
of the chest muscles is desirable, they should not be developed at the 
expense of the normal expansion of the "respiratory chest." The 
aim should be to improve the mobility of the chest and the lung 
capacity as well as to strengthen the muscles. 

Two kinds of breathing are usually spoken of: thoracic and ab- 
dominal. Breathing should be considered as a whole, unless one 
form is especially lacking, as, for instance, where a child has a very 
flat chest in which diaphragmatic or abdominal breathing greatly 
predominates over the thoracic, and there is Httle mobihty in the 
upper part of the chest. If the abdominal breathing needs to be 
developed, have the child stand in a good posture, with hands placed 
lightly over the lower ribs, Vv^ith tips of the fingers two or three inches 
from the median line, and take long, deep breaths until he secures a 
good movement of the lower ribs. The hands are placed over the 
ribs, only for the purpose of feeling the movement. 

All breathing exercises should be taken with the body in a good 
position and may be done while standing, lying, sitting, or slowly 
walking. Ordinarily they are taken in a standing position. If 
the muscles are weak or if it is difficult to stand in a good position, 
they may be taken in a sitting or reclining position. When the 
breathing exercise is taken reclining, a couch or a board resting on 
two chairs may be used in preference to a bed or the floor. A small 
hard pillow or a folded bath-towel may be placed under the shoulders 
and upper back, but should not extend under the head. Such a pad 
is used with advantage in cases of kyphosis and lordosis. 

It is better to take the deep breathing exercises in the open air, 
on the highest elevation in a nearby park, or during the daily 
outing, or even while walking to and from school, or while driving. 
But one must adapt himself to existing conditions, and if taken 
at home they may be taken on a piazza or balcony, or even 
indoors, with wide-open windows, but the air should be as free from 
dust as possible. If the windows are open in winter, the child should 
wear extra wraps or clothing. 

A breathing exercise should be preceded by a number of strong, 
sharp exhalations through the mouth in order to empty the lungs 
as thoroughly as possible of residual air, so that the deep inspirations 
may fill the lungs with fresh, pure air. 

The clothing should always be loose, with no constrictions at 
neck or waist. 

Holding the breath at the end of full inspirations may be done 
to advantage, if it is not held longer than five seconds. Retaining 



544 GYMNASTIC THKRAPBUTICS 

the air after full inspiration causes it to become warmer. As it 
becomes warmer it expands and penetrates the better into the 
alveoh. Retaining the air from one-half to one minute or longer 
is not wise. Becoming warmer, it continues to expand and may 
overdistend the alveolar walls. Prolonged holding of the breath 
has also a deleterious effect upon the heart. 

If, when the child begins to take deep breathing exercises he 
feels dizzy, he should not at first fill the lungs to their greatest 
capacity, or hold the breath, and each deep inspiration should be 
followed by several ordinary ones. After a few days the dizziness 
usually ceases. 

In all cases, deep breathing and respiratory exercises should be 
given. They are of special value in malnutrition, constipation, 
flat chest, and scoliosis. 

Breathing Exercises. — Take a good standing posture. 

1. Inhale deeply and exhale slowly. 

2. Place hands lightly on lower chest. Inhale deeply; exhale. 

3. Place hands Hghtly on upper chest, elbows well back and down. 
Inhale deeply; exhale. 

4. Inhale as arms are raised sideways to shoulder height. Ex- 
hale as arms are lowered. 

5. Inhale deeply as arms are raised forward and upward, to a 
vertical position. (From the beginning have elbows, wrists, and 
fingers straight, palms facing each other and separated by the 
breadth of the shoulders.) Exhale as arms are lowered sideways. 

6. Inhale as arms are raised sideways to vertical. (Elbows, 
wrists, and fingers straight — turn palms up when arms are shoulder 
high.) As vertical is reached, bend head slightly backward, stretch 
up and continue inhaling, while you slowly count three. Raise 
head; exhale as you lower arms sideways. (See Fig. 66.) 

In the illustration the wrists are strongly flexed and the palms 
are not turned, in raising to vertical. The action is stronger. Either 
position of the hands may be used. 

7. Arms at sides, elbows, wrists, and fingers extended. In one 
quick, continuous movement raise arms forward and flex forearms 
upon the chest, palms down, elbows drawn well back. At the 
same time a step forward is taken — the weight of the body is sup- 
ported over the forward foot, the ball of the other foot resting on 
the floor. With the above movement inhale deeply. Exhale as 
the arms are lowered to side. 

In Nos. 4, 5, 6, and 7, above, put the emphasis on the upward 
movement. In lowering the arms, keep chest high and arms well 
stretched, but make the movement an easy one. 

If the heart is weak, in the above exercises the arms should not 
be raised above the level of the shoulders, and all the exercises 
should be done more slowly and with less exertion. If the breathing 
becomes labored, or the countenance shows signs of interference 



BREATHING 



545 



with circulation, the child should rest until pulse and respiration 
return to their usual rate. 

Where deep respiration is an end in itself, in addition to the 
preceding breathing exercises, others which favor involuntary deep 
breathing should be given. It is important that a good posture 
be maintained throughout. 




m 



^ 



Fig. 66.— Breathing Exercise. 
Inhale as arms are raised, sideways, upward, to vertical. 

Exercises for Younger Children. — i. Walking up-hill at a mod- 
erate pace without stopping. 

2. Running in place, i, e., executing a running movement with- 
out advancing. 

3. Distance running — from fifty yards to a mile. The minimum 
distance to begin with, and the m^aximum distance to work up to 
in accordance with the general condition and age of the child. 

4. Running games, such as rolling a hoop, playing tag, etc. 
Exercises for Older Children— in addition to those just mentioned : 

1. Games, such as hand-ball, basket-ball, tennis, and football 
as played by boys. 

2. Swimming for distance, when accompanied by a competent 
person in a boat. 

35 



546 



GYMNASTIC THKRAPKUTICS 



FLAT CHEST 

In flat chest the weight of the body is usually carried too far 
back, the abdomen and head being too far forward. The chest is 
flattened, with ribs depressed, and there is interference with the 
proper expansion of the lungs. The shoulders often droop forward. 
The posture is one of general relaxation. 

Flat chest is of common occurrence among children during the 
years of school-life. It should be carefully corrected on account of 
the deleterious effect on the lungs and abdominal organs. The 
necessity for its correction should be impressed upon the child. 
Attention to posture and breathing is essential. The aim should 
be to give exercises which will strengthen the muscles of the back 
and neck, deepen and broaden the chest, and increase its elasticity 




Fig. 67.— Back Exercise. 
Raise head and chest high. 



and breathing capacity. In addition to the exercises given under 
Posture and Breathing, I have found the following of benefit in 
these cases: 

I. Have the patient lie prone on a hard, flat surface, hold the 
ankles while the patient raises head and chest as far as possible; 



KYPHOSIS ^ 547 

the arms extended and raised with the body, the backs of the hands 
being turned toward each other with the thumbs up. In the first few 
treatments, the thumbs may be clasped. Hold position for from two 
to five seconds, or while counting from one to five or ten. (See 
Fig. 67.) 

2. With knees straight, bend trunk forward until the hands touch 
the floor in front of the toes, or come as near to floor as possible, 
then raise the body to best possible standing position. Keep weight 
well over balls of feet, raise the chest as high as possible, stretch 
the arms well down at the side ; wrists, fingers, and elbows straight. 
Hold this position for from two to five seconds or while from five to ten 
are counted. The primary value of the exercise is in the elevation of 
the chest; secondarily, the back muscles are strengthened and, in 
bending forward, the muscles that elevate chest are relaxed so that 
they are better able to give a strong contraction when the body 
is raised. 

3. Have patient seated on a stool or low chair and stand be- 
hind him. Patient swings straight arms forward upward to vertical, 
palms facing. He then turns palms forward and grasps your hands 
and pulls his elbows backward and downward close to sides. As 
he pulls them downward resist his movement. 

KYPHOSIS 

Kyphosis, as considered here, is an increase of the normal curv^e 
in the dorsal region of the spine, commonly called *' round-shoulders," 
produced by weakened muscles and bad habits of posture, or some- 
times by improperly arranged clothing, and by the occupation of the 
child. These causative factors should be removed as far as possible, 
and, as in all the deformities of childhood, attention should be 
given to posture, breathing, arrangement of clothing, etc. 

The treatment given under Flat Chest is appropriate here, as the 
two conditions are often associated. The following exercises may 
be added: 

1. Raise arms sideways to height of shoulders. Bend head back- 
ward with chin drawn in and at same time turn palms strongly 
upward. When patient has learned to do this well, as the head 
goes back the arms may be raised to vertical. 

2. Flex forearms upon chest, palms down and elbows well drawn 
back, shoulders level. IncHne head slightly backward and fling 
arms forcibly sideways. 

3. Raise arms sideways to shoulder level, turn palms up, make 
three short circles with arms, stopping with the backward movement. 
Raise arms a few inches, stretch out and up. Bring arms backward 
and downward to sides. (See Fig. 68.) 

4. Hanging exercises: A short curtain pole, i-| inches in diam- 
eter, may be placed in a doorway at desired height. Strong enough 
sockets can be obtained at a hardware store. 



548 GYMNASTIC THERAPEUTICS 

(a) Hang with overgrasp. 
(6) Hang and swing. 

Hanging is of much value in kyphosis and flat chest on account 
of its effect upon the spine and spinal muscles. 

(c) Holding patient (see Fig. 69) ; trunk of patient resting 
against your body. 

(d) Holding patient ; upper back resting only against body. 
Exercises "c " and "d" are used for the passive stretching of the 

lumbar and dorsal portions of the spine. The dependent part of 
patient's body acting as weight to stretch the spine. Hold from 
one-fourth to one-half minute. Repeat several times. 





Fig. 68.— Chest Exercise. 
Stretch arms strongly. 

5. Patient sitting on stool or chair with arms forward midway 
between horizontal and vertical, palms facing. Make resistance as 
arms are separated backward and downward. (See Fig. 70.) 

6. Forearms flexed upon upper arms, hands closed and facing 
the front of shoulders. Strongly rotate forearms outward and 
backward. (See Fig. 71.) 

7. Patient sits astride a stool and raises the arms sideways. With 
an assistant, either the child's mother or nurse, on one side, and 
yourself on the other, each grasp the patient's hand with one hand and 
place the other hand on his back in the region of greatest deformity. 
Have the patient pull the elbows close backward and downward to 
the sides, against resistance. At the same time gentle and firm 
pressure is made on the back. 



KYPHOSIS 549 

8. Patient sits on stools, places hands low on hips, fingers for- 
ward and wrists straight, elbows drawn well back. Let him bend 
forward from hips with back straight. Place your hands over the 
regions of greatest deformity and have patient raise the body against 
resistance. The back must be kept straight, head erect, and chest 



Fig. 69. — Weight of Pelvis and Lower Limbs to Stretch the Lumbar Spine. 

well arched. When the patient can do this well, his hands may 
be placed on the back of the neck, instead of on the hips. 

9. The patient stands, raises arms sideways, shoulder high; 
bends trunk forward from hips, back straight, and raises arms to 
vertical. 

10. Patient lies face downward over end of couch or table, the 
whole body straight, hips and thighs only, resting on table and held. 



550 



GYMNASTIC THKRAPKUTICS 



Hands back of neck. Bend body forward until the chest touches 
the seat of a chair, then raise body as high as possible. (See Fig. 72.) 
II. While the patient is in dorsal recumbency, with one hand 
hold his knees firmly to prevent his body moving and have the other 
hand under his shoulders. Have an assistant (any adult) draw the 
patient's arms as strongly as possible in a line with his head and 
body, but away from them. When this is done, with the hand under 
the shoulders, gently but strongly raise his shoulders and body 
several inches from the table, hold while you count from five to ten, 
lower, and relax. Repeat from five to ten times. 



•r"T--:.;;n:'«xffr ^'^^^-s^^ 



/ 




\ 



MM^^'' 




Fig. 70.— Sit behind Patient and Give Resistance on Back of Wrists as He Separates 

His Arms. 



12. With children who are not strong begin with exercises in a 
reclining posture : 

(a) Reclining position. Arms extended at right angle to the 
body, palms facing each other. Separate arms against resistance. 

(6) Reclining position. Arms extended beyond head in line with 
the body. Bring arms sideways, downward, against resistance. 

(c) Deep breathing. 

id) No. 3 under Posture Exercises, but body arched only from 
hips upward, instead of from heels. 



SCOLIOSIS 



551 



In the treatment of kyphosis or flat chest with lordosis this 
exercise may be given. While a child is taking deep breathing or 
chest raising alone, lying in a dorsal position with or without the 
shoulders being raised by some supporting object, place your hand 
under the small of his back; after the chest has been fulhv^ raised, 
have him endeavor to press his back against your hand without 
lowering his chest. This may be done from fifty to one hundred 
times. Later, the same exercise may be done in sitting or standing 
positions, the lumbar region being pressed backward while the chest 
is elevated and forward. The lumbar spine should be brought back 
only until the entire back 
is in one straight line. 

The spinal muscles 
should be massaged to 
make them pliable. 

SCOLIOSIS 

Scoliosis, or lateral 
curvature of the spine, 
is a condition in which 
the spine deviates in 
whole or in part to one 
side or the other of the 
median line. It is ac- 
companied by the rota- 
tion of the vertebrae, 
though in some cases the 
amount of rotation is so 
slight that it is not easily 
detected; in other cases 
the rotation is marked 
in comparison with the 
amount of lateral curva- 
ture. 

The treatment of cur- 
vatures resulting from 
such diseases as tuber- 
culosis or caries of the spine, rickets, etc., will not be considered, 
but only the simple curvatures which occur in cases of general 
debiUty, muscular weakness, or are the result of faulty habits of 
posture, a short leg, certain occupations, etc. 

Diagnosis. — In the treatment of scoliosis, much depends upon a 
careful diagnosis. As far as possible all the etiologic factors should 
be ascertained: the heredity, general constitution and tempera- 
ment of the patient; the general appearance, condition of 
skin, the musculature, its structure and tonicity, should be closely 




Fig. 71.— Bring Forearms Back as Far as Possible. 



552 GYMNASTIC THlSRAPEUTlCS 

scrutinized. The patient's habits of posture while standing and 
sitting, especially when he is unconscious of observation, should 
be studied carefully. Inquiry should be made as to position during 
sleep, and if a school-child, concerning the desk, and chair and posi- 
tion while writing, etc. 

For examination the back should be bared down to the 
level of the trochanters, when the height of shoulders, height 
and prominence of hips, position of the scapulae and their relation 
to the spine, the lines running from the tips of the ears to 
the tips of shoulders, and the position of arms as they hang at the 
sides, should all be noted. The position of the spine itself and its 
relation to points mentioned should also be closely observed, when 



Fig. 72.— Movement May Start from Position oe Complete Flexion or Partial Flex- 
ion WITH Body Resting on Seat of Chair or on Shorter Stand or Table. 

the patient is standing in his usual posture, and again when he is 
standing in his best possible position. The position of the spinous 
processes should be marked with a flesh pencil and the curve carefully 
studied out; the contour and relative size of legs should be noted 
and the feet should be examined. To ascertain the amount of rota- 
tion, the patient should be made to take the Adam's position.^ If any 
difference is found in the height of the hips, a careful measurement of 
the legs should be made. Another important point to be determined 
is the flexibility of the spine, for to a great extent the diagnosis depends 
upon this. 

On the front of the body, the position of ribs, end of sternum, 
umbilicus, and the tension of the abdominal muscles should be noted. 

1 Patient stands with heels together, knees well stretched, bends body for- 
ward from hips; head and arms hanging forward. 



SCOLIOSIS 553 

Besides the above examination, it is well to inquire into the 
historv of the patient, as to diseases of childhood, present ailment, 
liability to certain diseases, as to amount of exercise both outdoors 
and indoors, and as to the condition of the digestive organs. Ex- 
amine heart and lungs. Certain measurements may be taken, such 
as height, weight, height sitting, girth of neck, chest, waist, hips, 
biceps, calves and insteps, depth of chest and abdomen, and breadth 
of shoulders, chest, and waist. 

I have found the best method of recording to be by photographing 
the patient, using a thread screen, the spinous processes and lower 
border of scapulae having been outlined with flesh pencil or dots of 
ink. To record the rotation, a lead tape may be molded across the 
posterior thorax at point of greatest convexity, while the patient is 
in the Adam's position, and the tape carefully removed and its out- 
line traced on paper. 

The curve may be a single long curve, a double, or a triple one. 
Endeavor to find out which is the primary, and which the secon- 
dary or compensatory curve, for the normal position of the spine is 
the result of the adjustment of the weight of the body around the 
center of gravity, in order to balance the body while standing or 
sitting, and if there is a change in the normal adjustment of the 
weight in one part, there must soon be a corresponding change else- 
where, so that if there is a left convexity in the lumbar region there 
will be a compensatory curve to the right in the dorsal. 

Treatment. — The treatment should be both general and local. 
In the general treatment, carry out a thorough hygienic regime, 
which includes exercise in the open air, baths, attention to diet and 
bowels, clothing, and general light exercise for muscle-building and 
stimulation of the circulation, respiration, and digestion. One of 
the most important things is to train the habits of posture. 

Special Tvcaimeni. — Massage and exercises which act strongly 
upon the spine itself, and suspension, with and without pressure, I 
have found most useful. It is occasionally of benefit to have " a 
patient wear a plaster cast or leather jacket during the day, betw^een 
treatments. 

At first only general movements are given, those in which both 
sides of the body are used equally, such as those found under Posture 
and Breathing, and adding, a little later, the exercises under Flat 
Chest and Kyphosis, with simple movements of the body to 
strengthen the spinal muscles and make the spine more flexible. 

The following may be used: body-bending forward, backward, 
to right and to left, and body-twisting to right and left. These 
movements may be done sitting or standing, and with the hands 
at the hips, back of neck, or extended over head. 

In giving a new exercise, the body should be bare, in order that 
its effects may be carefully noted. 



554 



GYMNASTIC THERAPKUTICS 



■mmsimimMtitmi^imttmmm 



In giving corrective bending and twisting movements, the bend- 
ing should be toward the side of the convexity with added pressure 
at the point of greatest curvature, and the twisting movement 
toward the side of the concavity with pressure over the point of the 
convexity. The following are some of the special exercises: 

A typical S-shaped curve, convexities, right dorsal and left 
lumbar, has been taken to illustrate the treatment. These exer- 
cises can be reversed. A single or triple curve will have to be 

studied out with back 
bared. 
-^ I. Hanging from bar ; 

pressure over convexities. 
(See Fig. 73.) 

2. Hanging from bar. 
Place your hand over 
point of greatest con- 
vexity, and push pa- 
tient's body sideways. 

3. Hanging from bar. 
Have patient extend the 
leg corresponding to the 
side of lumbar convexity 
backward against resist- 
ance. 

4. Lying prone on 
table; left hand on 
neck, right on hip: raise 
body. (See Fig. 67, but 
with hands placed in 
accordance with text.) 

5. Lying prone on 
table; hands on neck. 
Carry patient's legs to- 
ward the convexity of 
the lumbar region. 

6. Patient sits astride 
a stool; hands back of 
neck. Twist body to left ; 
make pressure over right 
dorsal region. 

7. Sitting on stool; left hand back of neck, right at hip; right 
leg extended backward. Bend body forward: resist patient as he 
raises body, using pressure over convexities. (vSee Fig. 74.) 

8. Standing: flex forearms on upper arms, with fingers pointing 
over shoulders. Extend left arm upward and right arm downward 
and backward, and extend left leg backward. 





Fig. 



73-— Spine Being Stretched by Weight of 
Body, Pressure over Convexities. 



SCOLIOSIS 



555 



9. Using wand, that is about twelve or fourteen inches shorter 
than the height of the body; grasp at ends, with elbows straight; 
swing strongly from front of thighs to the right, sideways, backward, 
until the wand is at a perpendicular and in line with the spine. The 
body arches from heels to head. (See Fig. 75.) 

"Key-note position."^ Left arm extended upward; right arm 
sideways. (See Fig. 76.) 




Fig. 74-— Body Raising with Pressure over Convexities. 



10. (a) Take "key-note position" standing. Stretch body for 
from two to five seconds. 

(b) Take ** key-note position." Marching on balls of feet. 
■ Do not give more than three or four special exercises in any one 
treatment, and follow each of them with a marching exercise, such 
as 10-b, or some breathing exercise. 

^ Key-note position is the position of arms by which the spine assumes its 
best position. 



556 



GYMNASTIC THERAPEUTICS 



CONGENITAL ATAXIAS 

The ataxias of childhood, to which we refer, are hereditary cere- 
bellar ataxia and hereditary spinal ataxia. Most observers have 
described them as beginning to develop at the age of eight or ten 






Fig. 75. — Swing Strong- 
ly TO This Position 
WITHOUT Bending El- 
bows. 



Fig. 76. — Key-note Position. 
Arm corresponding to low shoulder is raised. Used 
to maintain a better position of the spine during certain 
exercises and marches. 



years; one or two observers have mentioned a much earlier period, 
stating that the symptoms generally appear at the age of three or 
four years, and that the cases may be congenital. 

Cases upon which this treatment is based were congenital ; the 
development of the physical movements was retarded and defective 



CONGENITAL ATAXIAS 557 

from the beginning, and in one case of hereditary spinal ataxia the 
physical act of nursing was also defective. 

Hereditary cerebellar ataxia is characterized by the involvement 
both of the upper and lower limbs at the same time, although the 
upper limbs may not be ataxic to the same degree as the lower. 
The gait is reeling, uncertain, with the feet wide apart, body bent 
forward, the weight of the body being supported mainly upon the 
balls of the feet, the toes inclining inward, locomotion at times being 
interfered with by the crossing of the legs. One leg is usually 
more ataxic than the other. The reflexes may be increased. The 
speech is hesitating, defective, and explosive, but audible. 

Hereditary spinal ataxia {Friedreich's ataxia) is characterized by 
its beginning in the lower limbs, gradually extending to the upper 
limbs, and finally involving the organs of speech. The symptoms 
are vertigo ; swaying from side to side on standing ; marked muscu- 
lar weakness, especially of the extensors and abductors (paralysis 
may follow) ; contractures of the flexors and adductors ; scoliosis 
and talipes resulting, first, postural, through muscular weakness, 
later becoming fixed; rheumatoid pains; and diminution or loss 
of the patellar reflex; the head is held to one side in a clonic spasm, 
but turns from one side to the other every day or two; one leg is 
more ataxic than the other. The movements are characterized 
by rigidity and incoordination; the articulation is scanning and 
explosive, and oftentimes, for days, the patient cannot speak above 
a whisper. 

Dana states that there may be a mixed or transitional heredi- 
tary cerebellar and spinal ataxia. 

Some observers state that there is defective mentaUty, and that 
the patients possess a violent temper. I have not found either to 
be true — the temper being no different from that which you would 
find in a little patient otherwise ill for as long a period, and who was 
not perfectly understood. The speech, or the poise of the head, 
may suggest deficient mentality, but I have found these children 
affectionate, observing, and rational, and showing hereditary indica- 
tions of brightness in mechanical, mathematical, or methodical lines. 

In beginning treatment, study the patient's capability for co- 
ordinate action. Do this throughout the entire course. When 
you have decided upon the exercises to be given, show them to the 
patient in detail, explaining them fully, so that he may understand 
what effort is required, and occasionally, in teaching, repeat these 
illustrations and explanations. 

Accuracy is of the first importance. If there is lack of control in 
movement, pause and hold patient in correct position while you count 
from one to four or ten before resuming movement. Follow that 
practice as long as it is necessary, and at every tendency toward 
losing control. Slow and accurate work first, later more rapid work. 



55^ GYMNASTIC THKRAPKUTICS 

While learning an exercise of coordination permit patient to use 
his eyes to watch his limbs, in order that the coordinate centers 
may thus be reinforced or aided. Next rely only upon his muscular 
sense for correct execution, and at last have the eyes closed in order 
to eliminate the relationship of surrounding objects, which might 
aid in the execution. A rechning posture is assumed for coordinate 
training, where the patient is unable to stand. 

Do not expect a child to cooperate with you in attention or efforts 
to make his physical movements accurate when he is left to himself, 
for it is rarely done. The coordination must become reflex. 
The training must be carried to the extent of unnecessary capability. 
*'The keynote " must be, as with the orthopedist, over-correct, for 
the correct execution of work under observation would not be suffi- 
cient to insure coordinate action, the moment a child attempts to 
do things alone, or when he is tired, or when his attention is given 
to other objects. 

The aim in treatment should be in keeping with a child's natural 
sphere in life. Childhood is the time of muscular activity and growth ; 
it is the period of play and games. When a child is able to play at 
all, if left to himself he will not stop, for rest, when he begins to tire 
or fall ; he will do so only when the game is ended, and his companions 
finish. Play, therefore, serves only to increase the incoordination, 
because of overexertion. To make a child capable of walking or 
running at all, makes him eager to play when others play ; but it is 
like the fencing or boxing of two men, one of whom completely 
outclasses the other, whose native quickness and strength are com- 
pletely overcome; he has neither the opportunity to show them nor 
the mind to use them. The ataxic child, in playing with normal 
children, besides tiring more quickly, being outclassed, becomes 
bewildered and cannot seize the opportunity to attempt coordinate 
action. 

No satisfactory results can be expected from the treatment of 
ataxia, unless it is continued until the child is able to play as well as 
other children. The treatment should be made practical as soon 
as possible. Do not spend unnecessary time on gymnastics or 
apparatus. When a child shows that he is able to take one step, 
begin walking exercises, going up and down stairs, and running. 

Study the patient's movements, and analyze his defects in execu- 
tion. To tell a child not to fall when he is walking, and expect him 
to be able to avoid falHng, is not fair to the child. He does not know 
why he falls, and his attempts to avoid it only increase his gen- 
eral nerve tension. His f aUing may be due to one of several causes : 
it may be that he is walking with his feet widely separated; if so, 
he gets but little support from the advancing foot, and upon fatigue, 
diverting of attention, or striking a small obstacle, he will fall. 
When he permits his feet to separate, he should at once be directed 



CONGENITAL ATAXIAS 559 

to keep them close together. By so training the child, it will become 
easier to keep his feet in position, and, if there is no other defect, 
falling will unconsciously be avoided. So all of his work must be 
analyzed to discover its weaknesses or defects. 

General gymnastics have no place in the treatment of ataxia, 
but where certain groups of muscles are weak, movements may be 
given to strengthen them, in order that they ma}- do their part in 
coordination. Throughout the greater part of the treatment I 
have used exercises for strengthening certain groups of muscles, 
although their primary value was not to improve coordination. 
It is well to have these movements executed against resistance, in 
order to determine the amount of muscular power the patient pos- 
sesses. 

Coordinate efforts at balancing and walking are first made upon 
the floor until the child shows a little improvement, but it is 
difficult to make a child realize the necessity for using all of his ener- 
gies in the effort, when he knows that there is no particular danger; 
therefore apparatus is necessary to force coordination. Boards, 
blocks, and ladders (see Fig. 63) are used, not for the purpose of de- 
veloping ability to perform exercises upon them, but to develop un- 
consciously the habit of constant care and watchfulness, as the child 
can readily appreciate the fact that, Avithout such precaution, he will 
slip and fall ; he also learns that he cannot relax, whenever he is inclined 
to do so, as he might were he on the floor. By this apparatus work, 
children unconsciously acquire the ability to control themselves in 
places of danger into which their play leads them. 

Always place some incentive before the child, as otherwise he 
rarely puts forth the necessary exertion. His interest, attention, 
and muscular and nervous energy must be exerted. Tell him that 
it is necessary to do a certain amount of work before the treatment 
is over; that, when a certain amount is done, the treatment for 
the time will be over, whether the hour is up or not. Tell him that 
he must do something more than he did the day before, whether 
it takes longer than the hour or not. If it takes longer than the 
hour, he will learn that you mean what vou say, and sometimes 
the entire work of the hour will be executed in the last few minutes, 
despite the fact that the fatigue of the previous efforts makes it 
more difficult. 

While we wish to avoid fatigue, a certain amount is harmless. 
If a child remains fatigued at the end of an hour's rest, following 
the treatment, and he does not coordinate as well as before the 
treatment, provision should be made for more rest during the next 
treatment. A child's inertia needs to be overcome in spite of 
fatigue. It will teach him that merely saying he is tired will not 
enable him to escape the work. This has been impressed upon me 
by seeing how, after flfty-five minutes of unsuccessful effort, a child 



56o 



GYMNASTIC THERAPEUTICS 



will ''pull himself together," as it were, and do a new exercise that 
may really be difficult, in order that he may be able to leave at the 
end of the hour. 

Never permit a child to suffer a fall or injury during the treat- 
ment. Never take any risks with your patient. (See Fig. 77.) 
Falls cannot be prevented in ordinary walking, or running, except 
by words of caution, which should always be used; however, they 
should not be used in tests when the patient is endeavoring to see 
how far he can walk or run before he falls. On the first fall, make 
him return. 

Experience teaches a patient distrust of his ability to do a thing 




Fig. 77.— Walking on a Narrow Board Several Feet above the Floor. 
An advanced exercise in coordination. 



which he has never tried, or, having failed after several trials, he 
will naturally say he cannot do it, and not wish to attempt it. Con- 
fidence must be inspired in him to follow directions unhesitatingly 
by insisting upon his accomplishing every task given him, and thus 
proving his ability to do it, and also by showing him that his interest 
is yours, and that you have never permitted him to be injured dur- 
ing his unsuccessful attempts. 

With a child it is not enough to secure coordinate action, but 
you must secure endurance along the lines of reflex, coordinate 
action. Coordinate action with one who is ataxic calls for general 
tension, and the unnecessary accessory action of groups of muscles 



CONGENITAL ATAXIAS 56 1 

is fatiguing, and results in excessive waste of nerve and muscle 
energy. To teach a child to do his work easily and to carry on 
prolonged coordinate effort is thus accomplished by the same means. 
A parallel can be found in a person learning to skate or swim. Here 
we have a general tension and the general action of all the muscles 
of the body — a great waste of energy to prevent one from falling, 
or going under the water — and even after one has learned how to 
swim, much of that nervous waste of energy will continue until 
he has thoroughly mastered the art. Endurance and conservation 
of energy are very desirable in an ataxic. 

After he had been in training for several months one patient 
walked forward, without stopping, five hundred feet on the top of 
a fence, and backward one hundred and twenty feet without stop- 
ping. The same child walked several miles up and down a moun- 
tain-side without stopping, his mind occupied with observation 
and not applied at all to his walking, save in response to caution. 
He was able also to run half a mile without stopping or falling. It 
is not for the purpose of making the child a long-distance walker 
or runner that, after he has learned to walk or run properly, the 
distance is gradually increased to one or more miles, telling him to 
"take it as easy as possible" without stopping, although when 
fatigue is noticed sufficient rest should be given. It is common to 
see normal children of three or four years of age run and play 
for long periods of time without apparently tiring — our object in 
endurance exercises is to fit the patient for a child's sphere in life. 
Gradually the muscles become inured to fatigue, do their work 
with a minimum expenditure of force, and to a certain extent re- 
cuperate while in action. 

Short periods of retrogression must be expected occasionally 
throughout the entire course. When a child is tired, has had excite- 
ment, or when he is indisposed, one must expect a temporary loss 
of coordination. Parents too should be prepared for this, and not 
be disheartened when it occurs. 

The life of an ataxic child should be quiet and free from excite- 
ment. Judgment should be used about allowing him to mingle 
with other children, even though they are members of his own 
family. When allowed to play, it should be with younger children, 
if possible, or with his nurse, or mother, until the time of playing 
with other children is made a part of the treatment, and even then 
it should be confined, to lines permitted by the one in charge. In 
the intervals, a child needs sufficient quiet and rest, so that he will 
completely recuperate, and be in the best possible condition for the 
next treatm.ent, as the treatments afford the only hope of restoring 
him to nerve stability and normal muscular movement. As he 
improves, however, the daily regime should vary. As a rule, a 
child should rest, lying down from one-half hour to an hour before 
36 



562 GYMNASTIC THKRAPE^UTICS 

treatment, and the same length of time after treatment, and, in 
fact, at any time during the day when incoordination becomes 
marked. 

Attention to the general health of the child is important. There 
should be a simple and nutritious diet, careful attention to the bowels, 
daily bathing, an outdoor life, taking the treatment whenever possi- 
ble in the open air. These things should not be neglected, as these 
patients are apt to have less resistance to disease than non-ataxic 
children. 

Illness does not cause a retrogression except temporarily through 
the weakness which follows it. With returning health and strength, 
progress continues. 

Cooperation is important. It is more necessary here than in 
any other chronic ailment. A child will recover in one -half the 
time if cooperation is conscientiously given by those in charge of 
the child. For illustration: the child is capable of walking, but 
walks on the balls of his feet, or crosses his feet frequently, causing 
him to lose his balance easily; whenever he does it, if he is called 
back, no matter what his object may be for going, until he has 
walked across the floor correctly, the next time he starts to walk 
it will not be necessary to call him back as many times, and the con- 
stant correct walking will gradually make it a reflex habit. If he is 
permitted to walk incorrectly it encourages incoordination and a 
careless habit. The course of nervous stimuli has been likened to 
the making of a new path in a jungle. Constant use will make it 
easy to travel, but if the old path of incoordination is used instead, 
the new path of coordination remains a difficult task for a much 
longer period of time. The lines of least resistance are followed, 
and the new must be made as easy as the old if we would have a 
child use it. 

Treatment should be for an hour daily. More than an hour's 
treatment is apt to produce general nervous fatigue. An ataxic child 
may need training along many Hues, and the attempts to do one 
thing correctly may require so long a time that it is unwise to at- 
tempt to give work for the correction of all at one treatment. If 
this is attempted, nothing will be well done in the hour, and the 
work will only serve to tire the patient and increase the incoordina- 
tion. It would take a normal person, who could do the movements 
well, more than one hour to cover all the lines with improvement in 
each. An hour has been spent in endeavoring to walk a plank once 
without falHng off, but the child did it before the treatment was 
completed, and the next day he did it twice, so there was evident 
progress. When one morning hour is given to the lower limbs, work 
might be mapped out so that an assistant, the mother or nurse, could 
give another hour, or half hour, in the afternoon to exercises for the 
arms and fingers, or to massage, which would improve the nutri- 



CONGKNITAI. ATAXIAS 563 

tion of the tissues and the general circulation, so as to insure a 
better general response of the nerves and muscles. Another half 
hour could be spent in training the speech of the child. In this way 
the correction of the upper limbs and speech could progress at the 
same time as that of the lower limbs, instead of waiting until after 
the coordination in the lower limbs is first secured. 

Improvement in one line does not imply any special improve- 
ment in another. Walking, running, going up and down stairs, 
jumping, and hopping must each be taken up separately. It is 
particularly true, in case one is working for improvement in the 
lower limbs, and little attention is given at the same time to the 
upper. At the end of the time devoted to locomotion, the ataxia 
of the upper limbs is but Httle improved. 

Parents and physicians occasionally think that a child will out- 
grow his ataxia, but this is a mistake. 

A patient should hold as good a posture as possible at all times, 
as the weight of the body is then better adjusted. One or two 
exercises under Posture should be added to the treatment. The 
suggestions about clothing, under Posture (page 537), are especially 
valuable here. 

Five or ten minutes once or twice a day should be devoted to a 
sitting posture in which the body is held erect, but the limbs relaxed, 
and every part of the body entirely at rest. This aids greatly in 
overcoming the nervous instability and irritability, and is a valua- 
ble help in securing general nervous control. 

When giving the patient his treatment there should be no one 
else in the room, unless it is one whose presence would aid in securing 
better attention or work from the child. 

There is difference in the treatment of congenital ataxias and 
that of locomotor ataxia: In one case the patient is a child, in the 
other an adult. With the child, between treatments there is little or 
no cooperation; with an adult there is cooperation. During the 
period of development a child's sphere is that of play and muscular 
activity. The adult looks forward only to returning to his busi- 
ness or professional activity, and stops treatment when his pro- 
ficiency and coordination permit this. 

Exercises. — In the beginning, w^hen the child cannot walk, ex- 
ercises should be taken while lying down. For the lower limbs, 
they consist of coordinate flexions and extensions, abductions, ad- 
ductions, and circumductions, actively and against resistance, and of 
touching certain designated points or objects with the feet separately. 
In cerebellar ataxia one can more readily advance to the standing 
exercises, and take foot-placings (floor may be marked for this), 
stepping out to side, front and back and to the ordinary oblique 
positions, forward and backward. The weight of the body is carried 
by the advancing foot, so that w^hen the movement is completed 



564 GYMNASTIC THKRAPEJUTICS 

the weight rests equally over both feet. Taking a step is now prac- 
tised, bringing up the other foot to the side of the foot advanced. 
This is done sideways, forward, and backward. Two or three steps 
are now attempted, a pause being made after each one until a per- 
fect poise of the body is obtained. This is continued until the child 
can walk across the room. At this time the defects shown in the 
walking should receive attention. 

The defects in walking or running are usually the following: 
carrying the weight of the body too far forward; not straightening 
the knees completely; the reeling gait; the crossing of the legs; 
walking with the feet separated ; turning the toes inward ; not lifting 
the feet sufficiently; not bringing the heels to the ground. As 
occasion arises, show the child his defects, and caution him against 
their repetition. In walking and running in the room, repeat the 
exercise if any faulty execution is noted. Instruct the meiribers 
of the household, who have charge of the child, never to ignore 
these defects, but always to insist upon their immediate correction. 
In the outdoor walking or running, the patient should always be 
in advance of you, so that his every movement may be observed. 
It is here that the correction of the defects should mainly take 
place. The following four movements aid in correction, and should 
be given every day for quite an extended period, in order that the 
weakened muscles may be strengthened for the required work of 
coordination : 

(a) Drawing up the knees against resistance; 

(b) Flexing the feet against resistance ; 

(c) Abduction of feet against resistance; 

(d) Extension of legs against resistance. 

In the full extension of the legs, the feet must be kept flexed. 

The child being able to walk across the room, work is begun upon 
the apparatus ; boards from 7 inches down to i inch in width by half 
an inch in thickness and 10 feet in length, of well-seasoned hard- 
wood; a ladder, the sides of which are ij by 2^ inches, 10 feet in 
length, and the rounds | inch in diameter by 12 inches long, placed 10 
inches apart in the ladder; 24 blocks of wood, 2 inches in thickness 
and 12 inches wide by 14 inches long. Beginning with the 7 -inch 
board, have the child walk over and back, with the arms in different 
positions, the eyes open and the eyes shut; one end of the board 
placed upon one block, and so on until one end is resting upon ten 
or more superimposed blocks. The board is placed upon supports of 
equal height, beginning with one block under each end, increasing 
the height until the board is about five feet from the ground. At 
each increase in height the various exercises are repeated. (See Fig. 
77.) Two five-inch boards can be used when placed upon the 
same supports, the boards being about eight or ten inches apart. 
The child can step from one board to the other, going from one end 



CONGENITAL ATAXIAS 



565 



to the other; and, standing in the center, he can step forward and 
backward from board to board. With boards placed together, walk 
forward and backward, the boards bending unevenly, as one foot is 
on each board. 

Using the blocks alone, arrange them for walking, at varying 
distances from each other; also make piles uneven in height, and 
have patient walk with the eyes open and the eyes shut on the blocks. 



^^r 



WF m 




78.— Walking on Rounds of Ladder, One End Raised Several Feet above Floor- 
AN Advanced Exercise in Coordination. 



Ladder Exercises. — Ladder flat on the ground, walking forward in the 
spaces between the rounds ; walking sideways and walking backward. 
Place one end of the ladder upon a block and add blocks gradually 
until the ladder reaches the height of the child's knee ; then begin 



566 GYMNASTIC THERAPEUTICS 

with both ends of the ladder placed on single blocks, gradually in- 
creasing the height until the ladder reaches the height of the knee ; after 
each change of height the walking exercise forward, sideways, and 
backward is repeated. When using the blocks the child may bring 
them from the pile and build the steps that he is to walk upon; 
standing upon the block previously placed upon the floor, he bends 
forward, placing in position the one he carries, repeating the process 
until all the blocks are arranged. When through walking over the 
blocks, he stands on the one next to the last one placed, bends over 
and picks up the last one, and may carry it back to the pile, walking 
over the blocks, or he may lift and raise it above the head, and pass 
it, either forward or backward, to you. The block may be carried 
by the child walking through the spaces of the ladder, and both 
ladder and blocks may be arranged in various forms to be walked 
over by the child. 

You may now take up the balancing work, w^here the weight of 
the body is carried on only a portion of the sole of the foot, as in 
walking on the rounds of the ladder. The ladder is first placed flat 
upon the ground, and the walking is done forward and backward. 
This is graded by raising one end of the ladder until the child can 
walk up and down on the rounds several times without a mistake, 
the ladder raised to an angle of 35°. (See Fig. 78.) 

In beginning the treatment, the child is instructed not to allow 
one foot to step directly in front of the other. By this time co- 
ordination is sufficiently mastered so that balancing as an exercise 
may be taken up, using the boards from 2 inches down to one inch 
in width. On these boards the child must place one foot in front of 
the other, and walk forward across it; next, walk backward, eyes 
open and eyes shut. 

When a child is able to walk fifty or sixty feet without falling or 
stopping to rest, the distance is gradually increased in outdoor 
walks, correcting defects when noticed, until he can walk a mile or 
more without their occurrence or without falling. 

When able to run across the room in a straight line, teach running 
in a circle. W^atch closely his running and do not allow the feet to 
be widely separated, or the w^eight of the body to incline too much 
forward. He should run with a firm stride and raise his feet well. In- 
crease distance until he can run half a mile without falling or stopping 
to rest. Later teach running up and down hill ; running short dis- 
tances, as from eighty to one hundred feet, as fast as he can, and stop- 
ping without falUng; trying to catch a person; racing with another 
child, who starts at a sufficient distance behind him, so that they 
will finish at about the same time ; running to catch a person who 
will dodge and run zig-zag and in circles. Playing with other chil- 
dren in running games, such as "cross-tag," "pull away," etc., hav- 
ing the other children so handicapped that by exerting himself to the 



CONGENITAL ATAXIAS 5^7 

utmost he will not be caught. During these games, if he falls, he 
should be obliged to run around the grounds once alone. 

Other indoor exercises are : whirling on one foot fifty times without 
falling ; repeat on the other foot ; alternate thus with eyes open and eyes 
shut ; running in a short circle fifty times without falling. Such exer- 
cises are helps to the running out of doors. Another helpful exercise 
is running several hundred feet out of doors, whirling around in 
the direction indicated whenever the command "turn right," or 
**turn left," is given, without falling. 

Walking Up and Down Stairs. — Begin with one or two steps and 
gradually increase until the length of the flight is reached, seeing 
that the feet are not separated, but that they advance in straight 
lines directty in front of the body. In walking up stairs, carry the 
weight of the body over the foot that is on the upper stair. In walk- 
ing down stairs, be sure that the heel is brought against the back of 
the stair, so that the foot at no time will rest on the edge. Keep the 
hands close to the sides of the body while walking up and down stairs 
with the eyes shut. Run up and down stairs with the eyes open 
and again with eyes shut, carrying articles while running. Always 
be near enough to the child for his protection in case of accident. 
The object is to train the muscular sense and make the coordination 
sufficiently reflex to enable the child to run or walk up the stairs 
alone without the danger of an accident. 

Jumping. — Draw a line with a piece of chalk; teach the child 
to incline his body slightly forward, bending knees a little, spring 
forward, aided by an upward swing of his arms. Jump for height 
and distance over the rounds of the ladder, from one space to another, 
and repeat, skipping one space. Jump from block to block, the 
blocks being separated at varying distances. Jumping over blocks; 
running and jumping. 

Hopping. — Hopping is much more difficult, as the spring is from 
one foot alone, and the landing on the same foot. In addition to the 
coordination necessary to balance upon one foot, is added the required 
effort to lift the body from the ground and the coordination required 
for balancing the body on landing, so as to avoid falling. The 
training is about the same as in jumping; hopping with either foot 
over a string ; hopping for distance ; hopping for height ; and making 
a succession of hops on the same foot, without touching the other 
foot to the ground ; the running hop. 

At the close of these exercises it may not be amiss to repeat what 
was stated at the beginning, that it is not desired to make the child 
an athlete, but distance walking, distance running, fast running, 
jumping, and hopping are exercises which children use in their play 
for long periods of time, and the coordination secured by the appa- 
ratus work is often of value in places of danger where their play is 
often apt to lead them. Coordination to this degree should be secured. 



568 GYMNASTIC THKRAPE^UTICS 

Exercises for the Upper Limbs. — In the beginning, the general 
movements of the fingers, wrists, forearms, upper arms, and shoulders 
may be practised, executing them slowly until the coordination is 
perfect in these movements. The above exercises are simple move- 
ments of flexion, extension, rotation, and circumduction. The 
educative movements, however, have mainly to do with the fingers. 

1. Flexing and extending the fingers. 

2. Slowly and gently touch the tip of the thumb to the tip of 
each finger and hold them together without pressure while five is 
counted. 

3. Simultaneously touch the tip of each finger to the tip of the 
thumb. 

4. Flex strongly the index-finger so that the end will touch the 
base of its second metacarpal bone. 

5. Flex strongly and adduct the thumb so that the tip of the 
thumb will press the tip of the little finger. 

6. Flex strongly and adduct the thumb so that its tip will press 
the base of the little finger. 

7. Needles: have them graded from the largest to the smallest 
size, grasp a fine thread between thumb and each finger of one hand 
in turn, and thread each needle ; repeat, using the other hand. 

8. Buttons: have them graded from the largest to the smallest 
obtainable, and have them sewed on to one strip of cloth, another 
strip of cloth having buttonholes to correspond. Practise buttoning 
and unbuttoning with thumb and index-finger of each hand. 

9. Pins : picking them up with fingers. Pick up the pins and press 
them through a stiff pasteboard box, forming various designs. 

10. With a pencil correctly held, make squares, triangles, parallel 
lines, etc., with and without dots as a guide. 

11. With a pencil correctly held, make figures and letters both 
large and small. 

The child can also use the exercises of piling coins and chips, 
touching hanging balls, placing pegs in holes, and similar games. 
Also throwing and catching a ball. A child should be made to dress 
and undress himself, and to feed himself, although as exercises, 
at the beginning, he may do them only in part. 

In eating, the spoon or fork should never be full, and the cup or 
glass should be only partly filled. The execution of the move- 
ments should be slow. 

Exercises for the Speech. — A child should be taught to enunciate 
numbers and letters distinctly. An interesting book should be read 
to him, reading one or more words at a time, and requiring him to 
repeat them correctly after you. 

Friedreich' s Disease. — In a w^ell-marked case, begin treatment with 
massage to improve the nutrition of the weakened and atrophied mus- 
cles and to help relax the spasm in the contracted muscles. In con- 



ANTERIOR POLIOMYELITIS 569 

nection with the massage, passive exercise of the limbs is given and 
gradual and persistent extension is made upon the contractures, 
endeavoring to gain a little each day until the limbs are fully ex- 
tended; then increase from day to day the time during which the 
limb is held at full extension and abduction. The degree of motion 
in the joints is utilized by giving active movements. In order 
that the muscles may become stronger, slight resistance is given to 
these movements, and greater attention paid to the strengthening 
of the weaker groups of muscles. When the muscles have moved 
the limbs as far as possible, the extension must be completed by 
stretching or by pressure. A child should be taught how to turn 
over, after pushing up his arms out of the way. When lying 
prone he should try to draw up his knees under his body, and when 
his arms become flexible enough and strong enough, he should raise 
up his body until he rests on his hands and knees; later he is 
required to raise himself until he is sitting upon his legs, which are 
flexed underneath his thighs. Have patient raise his body from a 
reclining to a sitting posture, with legs extended. Let him sit in 
a chair, which is low enough to permit him to place his feet upon the 
floor, but without any supporting arms. Let him rise from a sitting 
to a standing posture by drawing back his feet underneath him, 
and inclining his body slightly forward, then straightening up to a 
standing posture. Have him balance, upon standing, from a few 
seconds to several minutes, stretching his body up to its full height. 
Give foot-placings, then let him attempt a few steps, pausing after 
each step to straighten up, balance and ''make himself tall." From 
this point the treatment is the same as that of the ataxia of the cere- 
bellar type, except that the massage and work for overcoming the 
contractures must be continued indefinitel}^, or the progress will 
be slower. 

ANTERIOR POLIOMYELITIS 

Exercises should include action of all the groups of muscles of 
the limbs. The exercise of the muscles that are normal, or but 
little impaired, stimulates the nutrition of the neighboring impaired 
muscles. 

With the patient in a reclining position the thighs may be flexed, 
extended, abducted, adducted, and circumducted against resistance 
when possible. The leg may be flexed and extended, and the foot 
may be flexed, extended, abducted, and circumducted. These move- 
ments may be passive at first; later, when possible, they may also 
be taken standing. Flexion and abduction of the foot and extension 
of the toes are results which will come last. 

A faint response is sometimes seen after friction over the super- 
ficial points of the nerves supplying these muscles, or when the 
limb is immersed in hot water, and when seen the movements should 



570 GYMNASTIC THKRAPKUTICS 

be completed passively. As the muscles show signs of returning 
functions, the movements are repeated frequently during the day, 
but always stopped when the responsive motion becomes weaker, 
in order that fatigue may be avoided. When possible, the lightest 
resistance should be given, so that the power of the muscles 
may be better ascertained, and their work thus gradually increased 
by increasing the resistance. An added stimulus may be given by 
having the normal limb execute the movement with the paralyzed 
limb. Occasionally, movement is secured in all but one toe. Where 
there is improvement in any way in the paralyzed limb, the treat- 
ment should be continued, for cases have shown that muscles may 
respond to treatment even though there may be no faradic reaction 
for more than a year. 

When the patient is able to walk, walking and marching exer- 
cises should be taken up, such as walking on straight lines to and from 
certain objects, walking on the toes, walking with the arms sideways 
shoulder high, and with arms in a vertical position. The blocks, 
board, and ladder that are used in treating ataxic patients pre- 
viously described are of use here. A trough or the use of a narrow 
ladder with sides six or eight inches in width serves to help the 
patient overcome the outward throw of the paralyzed leg. Although 
the dimensions of the ladder are different, the walking exercises 
outUned in the treatment of ataxia may be followed in part. In 
walking, the patient should endeavor to keep the foot flexed as much 
as possible, touching the heel first in bringing down the foot. The 
following may also be given: walking on the heels for a short dis- 
tance; jumping; climbing a ladder, using hands and feet; running, 
but do not permit an outward throw of the paralyzed leg, it must- 
advance straight forward; hanging from a bar, swinging both legs 
forward, sideways and backward, keeping heels together, and with 
feet apart. A light basket-ball or foot-ball may be used for kick- 
ing. Have patient practise the drop-kick, and show you how hard 
he can kick. 

Exercises for the Arms. — Flexion, extension, abduction, adduc- 
tion, and circumduction of the upper arm; flexion, extension, and 
rotation for the forearm and wrist, with and without resistance. 
Have patient close hand as tight as possible, showing how hard he 
can strike. Have him catch a basket-ball and practise throwing 
it into a high basket at different distances. Drop a tennis-ball into 
his hands to catch; also toss and bound it for him to catch. Have 
him throw a tennis-ball for height and distance. The tendency is to 
throw the ball downward. Some of the special finger movements used 
in the treatment of ataxia, such as approximating the tip of the 
thumb and the tips of the fingers, the button exercise, the work with 
the pencil, etc., may also be given. (See page 568.) 

Passive Exercises. — Where there is any tendency to contracture 



CONSTIPATION 571 

in the groups of muscles not paralyzed, or in which the degree of 
paralysis is only slight, passive exercises should be given to secure 
a normal range of motion of the contracted groups either in leg or 
arm. This must be kept up throughout the treatment for the pur- 
pose of lessening or overcoming the tendency to deformity. Care 
should be used, however, in not carrying the passive motion beyond 
the normal range. 

Resistance applied to movements of contracted muscles serves 
to stretch them more than does the passive stretching. 

Massage. — Gentle, deep-kneading, light clapping and hacking, 
friction over the superficial points of the nerves, and general fric- 
tion should be given to the entire limb. 

Light hacking, vibration, and deep-kneading should be given 
to the spinal muscles. 

Fifteen minutes of massage should be given once or twice daily 
as long as the treatment is needed. 

CONSTIPATION 

In addition to the measures suggested in a previous section (pages 
181-186) for the relief of constipation, gymnastic exercises may 
be brought into use. 

These exercises are given with two objects in view: one, to 
strengthen the abdominal walls, which mechanically stimulate the 
intestine; the other, to stimulate the general circulation, which 
quickens the portal circulation and increases the activity of the liver. 

The first five exercises are taken from a reclining position. 

1. The knees straight and feet extended. Raise both legs until 
they are at a right angle with the body. 

2. Knees straight. Raise heels about four inches above couch; 
separate them as widely as possible ; bring them together, and lower 
to couch. 

3. Knees straight. Raise heels ten or fifteen inches above 
the couch. Draw up the knees as close to the chest as possible, 
without raising heels. Extend the legs without raising or lowering 
the feet. Lower legs to coucho 

4. Feet held, or secured by strap. Raise body to sitting position 
without use of hands. The hands may be placed upon the thighs, 
folded upon the chest, placed back of neck, or the arms may be ex- 
tended beyond the head. Changing the position of arms in the 
order named increases the exertion. 

5. Feet held. Circle trunk sideways, forward, sideways, back- 
ward to the starting position. Starting to right and left alternately. 
Arms position as in number four. 

6. Hang from bar or round of ladder. Execute No. i. (The 
position of body changed, but the relation of legs to body same as 
in No. I.) 



572 GYMNASTIC THERAPKUTICS 

7. Hanging position. Execute No. 2. 

8. Hanging position. Execute No. 3. 

9. Hanging position. Heels together, swinging legs from waist, 
describe as large a circle as possible with the feet. 

Each of the above exercises may be followed by a deep-breathing 
exercise. 

In a weak patient, the detail of straight knees need not, at first, 
be insisted upon. If necessary, the patient may be assisted, the 
weight of the legs or body being partly supported until the patient 
is strong enough to execute it alone. 

10. Sitting on chair or stool. Hands placed back of neck, twist 
body right and left against resistance. 

11. Sitting position. Hands back of neck, bend body right 
and left against resistance. 

Exercises for the General Circulation. — Taken from a standing 
position. 

1. Bend trunk forward, touch floor with fingers, keeping the knees 
straight. 

2. Take a long step forward, bend the forward knee; bend trunk 
forward; touch the floor with fingers. Raise trunk, step back to 
position. Alternate feet in stepping. 

3. Stand with feet two foot-lengths apart. Raise arms side- 
ways to shoulder height. Bend right knee and bend trunk to right 
side, touching floor with right hand. Raise body. Same to left. 

4. *' Chopping." Stand with feet separated, fingers interlaced. 
Bend body forward, swinging hands to floor between feet. Raise 
body, swinging hands up over right shoulder, at same time twisting 
to right. Swing to floor. Same to left. 

5. Hop, feet apart, then together, quickly. 

6. Run in place — i. e., without advancing. 

(a) With front of thighs kept in same plane with front of body, 
heels striking buttocks in running. 

(6) With each step in running, raise the knees as high as possi- 
ble in front of body. 

The running and hopping should be done quickly, and continued 
long enough to get the body thoroughly warm. 

Passive Exercises. — i. Trunk-rolling. Patient in a sitting posi- 
tion, feet separated and fixed. Grasp him by the shoulders, and 
with a continuous movement bend the body to the right, forward, 
left, back to the starting position. After the movement has been 
given several times, reverse the direction. 

2. Thigh-rolling. Patient in a semi-reclining position. Grasp 
patient's foot with right hand, his leg just below the knee with left. 
Raise thigh and circumduct it, the knee describing as large a circle 
as possible. 



FLAT-FOOT 573 

Exercises with Resistance. — i. Reclining position. Flex and ex- 
tend thighs. 

2. Semi-reclining position, with knees drawn up. Abduct and 
adduct thighs. 

The prescription for treatment may be arranged in this order: 
active exercises, passive exercises, exercises with resistance, ending 
with some deep-breathing exercises. 



FLAT-FOOT 

Flat-foot is a condition in which the ligaments and muscles 
of the foot are abnormally weak, and in which the anterior posterior 
arch may be partially or wholly depressed and flattened. 

The leg is rotated inward and the foot everted; the weight of 
the body falls on the inner side of the foot; the interior malleolus 
is prominent; the entire sole of the foot rests on the floor; and 
when the feet are placed side by side and the toes and heels touch, 
the natural concavity of the inner Une of the foot is replaced by a 
convexity. The patient complains of pain or weakness, and the 
tissues of the sole are weak and flabby. 

There are different methods of examining the outlines of the 
sole of the foot: standing with the foot on a plate of glass so that 
the sole of the foot may be seen from beneath; smearing the sole 
with vaselin and standing on a piece of blotting-paper; smearing it 
with charcoal and standing on a piece of white paper, etc. 

The patient should have proper rest. He should frequently 
sit with feet elevated, and avoid exhaustion. When standing, he 
should occasionally invert the feet, and, when walking, walk with 
the feet parallel, as the Indians do, and for short distances walk 
on the outer borders of the feet. 

The feet should be cared for each day, giving attention to the 
nails and to bathing. Apply hot and cold water alternately, and rub 
vigorously in order to stimulate the muscles and the circulation. 

The feet should be properly clothed; the stockings should be 
even, smooth, and loose, but should not heat the feet. The shoes 
should be broad enough to permit free use of the muscles of the feet ; 
the toe of the shoe should point slightly inward, and the inner border 
may be raised; the heels should be low and broad. 

The general condition of the patient should be carefulh^ considered, 
his general tonicity — for its impairment will affect the condition of 
the feet. Judgment should be used in the care and use of the feet 
in rheumatism, and during and shortly after convalescence where 
there is a general relaxation of muscles and ligaments. Malnutri- 
tion and obesity, if present, should receive attention while the feet 
are being treated. 

In severe cases, in the beginning, the patient should be kept en- 



574 GYMNASTIC THERAPEUTICS 

tirely ofif of his feet, and given only passive exercises, massage, and 
bathing. 

Exercises. — i. Redining or semi-recHning position. Extend foot 
against resistance. 

2. RecHning position. Adduct and invert foot against resis- 
tance. 

3. RecHning position. Circumduct foot inward, upward, and 
outward with resistance appHed to the inward and upward motion. 

4. Standing position. Raise on toes. 

5. Standing position. Raise on toes; turn heels outward; lower 
heels slowly to floor. 

Passive Exercises. — i. With one hand hold heel firm, at the same 
time pressing on the astragalus with an outward, upward motion 
of the thumb, while the other hand adducts, inverts, and flexes the 
foot. This may be done under hot water if the deforfnity is marked. 

2. Extension of foot. 

3. Adduction of foot. 

Massage. — Deep-kneading, vibration, and clapping may be given 
to the foot and to the muscles of the calf of the leg. 

A gauze pad may be placed under the arch, and held by adhesive 
plaster or a rubber bandage, until a well-fitted plate can be made, 
which should be used for support in the interA^als between treatments, 
until the muscles and ligaments have gained sufficient strength to 
hold the arch in a normal position. 



DRUGS AND DRUG DOSAGE 
FOR INTERNAL USE 



Drug. 



ACETANILID. 

Not advised in the treatment of chil- 
dren. 
Acid, Arsenious. See Arsenic. 
Acid, Benzoic. Benzoic Acid, Flowers of 
Benzoin 

Used in cystitis of alkaline type 

Acid, Gallic. 

Bismuth Suhgallate. (Dermatol.) 

Used internally as an intestinal astrin- 
gent, also externally, 

Acid, Hydrochloric, Dilute. (Corre- 
sponding to 31.9% of absolute 
HCl.) 
Used in chronic gastritis with atony 

of the stomach 

Acid, Lactic. 

Used in fermentative diarrheas. 
Given best well diluted with syrup and 

water and at 2 -hour intervals 

Acid, Phosphoric, Dilute. (Containing 
10% Orthophosphoric Acid.) 

Used as a stomachic 

Acid, Salicylic. 

Seldom used uncombined. 
Bismuth Subsalicylate. 

Intestinal astringent and sedative . . . 
Methyl Salicylate. (Synthetic Oil of 
Wintergreen.) 

Antirheumatic 

Oil of Wintergreen. (Natural.) 

Antirheumatic 

Salol. (Phenyl-salicylate.) 

Intestinal antiseptic and antirheu- 
matic 

Sodium Salicylate. 

Antirheumatic 

Aspirin. (Non-officinal.) (Acetyl-sali- 
cylic Acid.) 
Antirheumatic, — a substitute for So- 
dium Salicylate, i)eing less irritating to 
the stomach. Best given in capsules, 
for it is decomposed by alkalie^ and by 

moisture 

Acid, Tannic. 

Used in the form of: 
Tannalhin. (Dried Albuminate of Tan- 
nin.) 
Used as an intestinal astringent .... 

575 



Dose. 



6 Months. 18 Months. 3 Years. 5 Years 



gr. 1 



gr. 3-5 



gt. i-i 



gtt. 1-2 

gr. 1 

gt. 1 
gt. 1 

gr. i 
gr. 1 



gr. 1 



gfr. 1-2 



gr. 1-2 
gr.5 

gt. 1 

gt. 1 
gtt. 2-3 

gr. 1-2 

gtt. 2-3 
gtt. 2-3 

gr. 1-2 
gr. 1-2 



gr. 1-2 



gr. 1-2 



gr. 2 
gr. 10 

gtt. 2 

gtt. 2 
gtt. 5 

gr. 2 

gtt. 3 
gtt. 3 

gr. 2 
gr. 2-3 



Sfr. 2-3 



gr. 2-3 



gr. 3-5 
gr. 10 

gtt. 3-5 

gtt. 3-5 
gtt. 10 

gr. 3-5 

gtt. 3-5 
gtt. 3-5 

gr. 3 
gr. 3-5 



gr. 3-5 



gr. 3-5 



57^ DRUGS AND DRUG DOSAGE) 

DRUGS AND DRUG DOSAGE— FOR INTERNAL VSU— (Continued) 



Drug, 



Acid, Tannic (Continued). 
Tannigen. (Acetyl-tannin.) 

Used as an intestinal astringent .... 
Also by rectum : 1 % solution of Tannic 
Acid in an enema, for dysentery or col- 
itis. 
Acid, Tartaric. 

Seldom used except as one of its salts. 

Potassium Bitartrate. (Cream of Tartar.) 

Diuretic, refrigerant, and aperient. 

Used as an ingredient of diuretic drinks. 

To one pint of water to be drunk in 

twenty -four hours, is added : 

Potassium and Antimony Tartrate. 
(Tartar Emetic.) 
Used as an expectorant. Its action 
is too violent for use as an emetic. 
Best given alone or with Ipecac in a 
tablet or in a mixture with a simple 
elixir. 

May cause severe gastro-enteritis 

in too large doses 

Potassium and Sodium Tartrate. (Ro- 
chelle Salt.) 

Laxative 

Aconite;. (Aconitum Napellus.) (Root 
contains 0.5% Aconitin.) 
Tincture of Aconite Root (10%). 

Used in a beginning fever as a circu- 
latory sedative and an analgesic 

Alcohol. (Ethyl Alcohol, Spirits of 
Wine.) 
Best given as Whisky or Brandy for 
a general stimulant toward the end of 
an illness or as a last resort. 
Brandy. (Spiritus Vini Gallici, con- 
taining 39-47% alcohol by weight.) 

Whisky. (Spiritus Frumenti, contain- 
ing 44-50% alcohol by weight.) . . 

Sherry Wine. (Vinum Xerici, contain- 
ing Alcohol 15-20% by weight.) . . . 



Aloes. 

Not advised 
children. 
Alum. 

Not advised 
children. 
Ammonium. 

Ammonium Bromid. 
Ammonium Chlorid. 

Stimulating expectorant; best given 
dissolved in half an ounce of water 



in the treatment of 



in the treatment of 



See Bromin. 
(Sal Ammoniac.) 



Dosi 



6 Months. 18 Months. 3 Years. 5 Years 



gr. 1-2 



gr. 15 
gt. i 

gtt. 5-10 
gtt. 5-10 



gr- 



gr. 1-2 



gr. 30 



gt.i 



gtt. 10- 
20 



gtt. 10- 
20 



gtt. 30 



gr. i- 



gr. 2-3 



gr. T^o 



51-2 



gt. 1 



gtt. 20- 
30 

gtt. 20- 
30 

gtt. 45- 

31 



gr. 1 



gr. 3-5 



34 



gr. 100 



33-4 



gtt. 1-2 



gtt. 30- 
40 

gtt. 30- 
40 

31-2 



gr. 1-2 



FOR INTERNAIv USE 577 

DRUGS AND DRUG DOSAGE— FOR INTERNAL VSE— (Continued) 



Drug. 



Ammonium (Continued). 

Ammonium Carbonate. (Sal Volatile.) 
Stimulating expectorant ; best given 

dissolved in half an ounce of water 

Solution of A mmoniiim A cetate. (Liquor 
Ammonii Acetatis or Spirits of 
Mindererus.) 
Stimulating expectorant ; best given 
well diluted in carbonic water. 

Used also as a diuretic, antipyretic, 

and diaphoretic 

Aromatic Spirits of Ammonia. (Spiri- 

tus Ammonii Aromaticus.) 

Used as a stimulating expectorant, 

volatile stimulant, carminative, and 

antispasmodic. Best given well diluted 

with water 

Antimony. 

Antimony and Potassium Tartrate. 
(Tartar Emetic.) See under Acid, 
Tartaric. 
Antipyrin. 

Analgesic and sedative in pertussis 
and laryngitis. 

Best given alone in powder form, or 

with Sodium Bromid in solution 

Antitoxin. See Serum, Antidiphther- 

itic. 
Apomorphin. 

Not advised in the treatment of 
children. 
Arsenic. 

Arsenious Acid. (Arsenic Trioxid or 
White Arsenic.) 
Used in anemia, malaria, and 

chorea. 
Administered either in solution (see 
Fowler's Solution) or in tablets with 
other ingredients. 

In large doses it is an irritant poison 
causing puffiness of the eyes and gas- 
tro-entoritis, both of which are signs of 
an overdose. 

Cannot be given with astringents, 
tinctures, or decoctions, or with solu- 
tions of Iron. 

Antidotes are Hydrated Iron with 
Magnesia, egg-albumen, and emetics. 

Given three times a day 

Fowler's Solution. (Liquor Potassii 
Arsenitis.) 
Uses, action, and antidotes are the 
same as Arsenious Acid. 

Best given in water into which it is 
freshly dropped 



Dose. 



6 Months. 18 Months. 3 Years. 5 Years, 



gr. i-i 



gtt. 3 



gr- 



gr. J-1 



3i-l 



gtt. 3-5 



gr. 1-U 



gt. i 



gr. 27^ 



gt. 1 



gr. 1 



51 



gtt. 5 



gr. 1-2 



g:r. 2 



gr. Tio 



gtt. 2 



gtt. 5-10 



gr.3 



gr. xi^ 



gtt. 2-5 



31 



578 



DRUGS AND DRUG DOSAGK 



DRUGS AND DRUG DOSAGE— FOR INTERNAL US^— (Continued) 



Drug. 



ASAFETIDA. 

Emulsion of Asafetida. (Milk of Asa 
fetida.) 

Used chiefly as an ingredient of 
enemata, especially in excessive tym 

panites. To 8 ounces of diluent 

AsPiDiuM. (Male-fern.) 
Oleoresin of Male-fern. 

Teniafuge. 

Best given in emulsion or in cap 
sules 



Dose. 



6 Months. 18 Months. 3 Years. 5 Years. 



Aspirin. See under Acid, Salicylic. 
Atropin. See under Belladonna. 
Basham's Mixture. See under Iron. 
BeIvIvAdona, (From the leaves of the 
Air o pa Belladonna, containing 
0.35% of alkaloid.) 
Atropin. (Alkaloid of Belladonna.) 
Respiratory stimulant, antihidrotic. 
Used as a stimulant, a mydriatic, 

and for the cure of enuresis 

Tincture of Belladonna (10% leaves). 

Uses similar to Atropin 

Belladonna Leaves. (Asthma Powder.) 
Used occasionally with the leaves of 
Conium and Stramonium, and Potas- 
sium Nitrate (Saltpetre) to relieve at- 
tacks of asthma. To be burned in a 
metallic receptacle. 
Benzoic Acid. See Acid, Benzoic. 
BiCHivORiD OF Mercury. See under 

Mercury. 
Bismuth. 

Bismuth Suhcarhonate. 

Intestinal astringent and sedative. . . 
Bismuth Suhgallate. (Dermatol.) 

Intestinal astringent and sedative. 

Used also externally 

Bismuth Suhnitrate. 

Intestinal astringent and sedative. . . 

Bism^uth Subsalicylate. See under Acid, 
Salicylic. 
Blaud's Pii.1.. See under Iron. 
Borax. (Sodium Borate.) See under 

Sodium,. 
Brandy. See under Alcohol. 
Bromin, 

Used only in the form of its salts. 
Ammonium Bromid. 

Sedative. Used in laryngismus, 
pertussis, asthmatic bronchitis, and 
sleeplessness. 

Best given well diluted with water . . . 



S^' 50 



gr. 10 

gr. 3-5 
gr. 5-10 



gr. 1-3 



31 



gr- zh 
gt. 1 



gr. 10 

gr. 5 
gr. 10 



gr. 2-4 



51 



gr. 10- 
15 



gr. ^h 
gtt. 1-2 



gr. 10 



gr. 5-10 

gr. 10- 
15 



gr. 3-5 



51 



gr. 20- 
30 



gr. ^l-o 
gt. 3-5 



gr. 20 

gr. 10 
gr. 20 



gr. 5-8 



FOR INTERNAIv USE 



.579 



DRUGS AND DRUG DOSAGE— FOR INTERNAL VSE— (Continued) 



Dose. 



Drug. 



Bromin (Continued). 
Potassium Bromid. 

Used same as the Ammonium salt, 

but it is more depressing 

Sodium Bromid. 

Used same as the above. It is mid- 
way between the Ammonium and the 
Potassium salts in its depressant action . 
Strontium Bromid. 

Used same as the above 

Brown Mixture;. See under Liquorice. 
Caffein. 

Citrate of Caffein (50% Caffein). 

General stimulant and diuretic 

Calcium. 

Calcium Chlorid. 

Of some benefit in hemophilia and 

purpura hemorrhagica 

Calcium Sulphid. 

Antipustulant 

Prepared Chalk. 

Antacid 

Compound Chalk Mixture. (Mistura 
Cretae Composita.) 
20% Chalk Powder, 40% Cinnamon- 
water. 

Antacid. Every 2 hours 

Calomel. See under Mercury. 
Camphor. 

Powdered Camphor. 

Used in coryza. Every 2 hours .... 
Spirits of Camphor (10% in Alcohol). 

Stimulant, anodyne, carminative. . . 
Water of Camphor. (Aqua Camphorae.) 
(Contains 0.8% of Camphor.) 
Used as a vehicle. 
Cantharides. 

Used best in: 
Tincture of Cantharides (10%). 

Useful in cystitis and functional 

albuminuria 

Capsicum. 

Used best in: 
Tincture of Capsicum (10%). 

Used as a carminative and stom- 
achic. Best given well diluted in 

water 

Cardamom. 

Used best as: 
Tincture of Cardamom. 

Used as a carminative 

Cascara Sagrada. (Bark of the Rham- 
nus Purshiana.) 
Extract of Cascara Sagrada. 

(Four times the strength of the bark.) 
Tonic laxative 



6 Months. 


18 Months. 


3 Years. 


5 Years. 


gr. 1-3 


gr. 2-4 


gr. 3-5 


gr. 5-8 


gr. 1-3 


gr. 2-4 


gr. 3-5 


gr. 5-8 


gr. 1-3 


gr. 2-4 


gr. 3-5 


gr. 5-8 


gr.i 


gr. i-l 


gr. 1 


gr. 1-2 


gr.i 


gr. 1 


gr. 1-2 


gr.2 


gr. -so 


gr. 2V 


gr. 2V 


gr. T^ 


gr.2 


gr.3 


gr. 5 


gr. 5-8 


51 


51 


5H 


52 


gr. tV 


gr.i 


gr.i 


gr.i 


gtt. 3 


gtt. 5 


gtt. 5-10 


gtt. 10 


•• 


•• 


gt. i-i 


gt. i 




gt. 1 


gtt. 2-3 


gtt. 3-5 


gtt. 5 


gtt. 10 


gtt. 15 


gtt. 20 




gr. i 


gr. 1-2 


gr.3-5 



580 DRUGS AND DRUG DOSAGE 

DRUGS AND DRUG DOSAGE— FOR INTERNAL VSU— (Continued) 



Drug. 



Dose. 



6 Months. 18 Months. 3 Years. 5 Years, 



Cascara Sagrada (Continued). 

Fluidextract of Cascara Sagrada. 

(Aromatic.) (1 c.c. = 1 gm, bark.) 

The active principles are retained, 

but the bitter principles are eliminated. 

Tonic laxative 

Castor Oil. (Oleum Ricini.) 

(Expressed from the seeds of Ricinus 
Communis.) 

Bland oil and cathartic. 

Given usually for one dose 

Cerium Oxalate. 

Sedative in vomiting . 

Chalk. See Calcium. 
Chloral Hydrate. 

Sedative, hypnotic, and antispas- 
modic. 

Best given in some bland fluid by 

rectum 

Chloroform. 

Given internally as : 
Spirits of Chloroform. (Chloric Ether.) 
(6% Chloroform.) 
Carminative, antispasmodic, and sed- 
ative 



Water of Chloroform. (Aqua Chloro- 
formi.) (0.5% Chloroform.) 

Vehicle and carminative . 

Cinchona. See under Quinin. 
CocAiN, or: 

Cocain Hydrochlorid. 

Local anesthetic by hypodermic 
injection. 

Used in 0.2% to 4% strength. _ But 
seldom used for local anesthesia in 
children. Used by the mouth in 

obstinate vomiting 

CoDEiN. See Opium. 
CoD-LivER Oil. (Oleum Morrhuse.) 
Fixed oil from fresh cod's livers. 
Alterative and tonic. 
Given three times a day 



Corrosive Sublimate. See Corrosive 

Chlorid of Mercury. 
Cream of Tartar. See under Acid, 

Tartaric. 
.Creosote. (Beechwood Creosote.) 

Tonic, alterative, and antitubercu- 
lar. 

Best given in an emulsion with 
'Cinnamon-water, three times a day 
•after meals 



gtt. 15 



51 

gr. 2 



gtt. 2-3 



3i 



gtt. 30- 
45 



32 

gr. 2-3 



gr. 1 



gtt. 3-5 



3i-2 



gtt. 10- 
15 



gt. i 



gr. 



gtt. 15- 
20 



31 



33 

gr. 3 



gr. 14 



gtt. 5-55 



32-3 



31-2 



34 



gr- 



3-5 



gr. 2 



gtt. 15- 
20 



34 



gr. 



gtt. 20- 
30 



gtt. 2 



gtt. 2-3 



gr. 



3i-i 



gtt. 3-5 



FOR INTERNAL USE 58 1 

DRUGS AND DRUG DOSAGE— FOR INTERNAL VSU— (Continued) 



Drug. 



CrKosote (Continued) . 

Creosotal. (Carbonate of Creosote — 
92% Creosote.) 
Is preferable to Creosote because 
it has little odor, a more agreeable 
taste, and is better borne by the stom- 
ach 

Dermatol. (Bismuth Subgallate.) See 

under Bismuth. 
Digitalis. (From the leaves of Digitalis 
Purpurea.) 
Heart stimulant and tonic; also 
diuretic. 

Best given by mouth in the form 
of the Tincture and hypodermically 
either as the Tincture or as Digitahn. 

Tincture of Digitalis (10% leaves) 

Infusion of Digitalis (66 gm. = 1 gm. 

leaves) 

Digitalin (ten times strength of leaves). 
Diphtheria Antitoxin. See Serum, 

Anti- diphtheritic. 
Dover's Powder. See under Opium. 
Epsom Salt. See under Magnesium. 
Ergot. (From the sclerotium of the 
Claviceps Purpurea of Rye.) 
Hemostatic, heart and circulatory 
stimulant. 
Fluidextract of Ergot (1 c.c. = l gm. 

Ergot) 

Eriodyctyon 
Ether. 

Used internally as: 
Compound Spirits of 

mann's Anodyne, 32.. 
Anodyne, carminative, 
modic, and stimulant. 

Best given well diluted with water. . . 

Spirits of Nitrous Ether. (Sweet 

Spirit of Niter, 4% Ethyl Nitrite.) 

Used as a diaphoretic, diuretic 

and carminative. 

It is volatile and explosive and 
incompatible with many drugs. Best 

given alone or in a simple elixir 

Fel Bovis. See Ox-gall. 

Ferrum. See Iron. 

Fowler's Solution. See Arsenic. 

Gallic Acid. See Acid, Gallic. 

Gentian. 

Extract of Gentian. 

Stomachic and bitter tonic. 

Given three times a day 

Glauber's Salt. (Sodium Sulphate.) 
See under Sodium. 



See Yerba Santa. 



Ether. 



(Hoif- 
, Ether.) 
antispas- 



DOSE. 



Months. 18 Months. 3 Years. 5 Years, 



gt. i 



gt. h 



gr- 2^7 



gtt. 2-3 



gtt. 2 



gtt. 2-3 



gtt. 2 



gt. 1 

gr- ^-^0 



gtt. 5 



gtt. 3-5 



gtt. 3-5 



gtt. 2-3 



gtt. 1-2 

oi-1 
gr. ih 



gtt. 5-8 



gtt. 5 



gtt. 5 



gr. i-i 



gtt. 3-5 



gtt. 2-3 

31-3 
gr- Ths 



gtt. 10- 
15 



gtt. 5-10 



gtt. 5-10 



gr. i-1 



582 DRUGS AND DRUG DOSAGE 

DRUGS AND DRUG DOSAGE— FOR INTERNAL VSU— (Continued) 



Drug. 



GivONOiN. See Nitroglycerin. 

GivYCSRIN. 

Used chiefly as a demulcent base 
and a vehicle for other drugs. 
Glycyrrhiza, See Liquorice. 
HEXAMETHYiyEjNAMiN. Oflicial name for 

the proprietary Urotropin, q. v. 
Hoffmann' s Anodyne. See under Ether. 
Hydrargyrum. See Mercury. 
Hyoscyamus. 

Tincture of Hyoscyamus. 

Sedative and antispasmodic. 

Iron. Given every two hours 

Liquor Ferri et Ammonii Acetatis. 

(Basham's Mixture — Solution of 

Iron and Ammonium Acetate — 10% 

metallic Iron) 

Ovoferrin. (Proprietary Organic Iron.) 

Pyrophosphate of Iron (10% of metallic 
Iron) 

Syrup of the lodid of Iron (5% Ferrous 
lodid) 

Tincture of the Chlorid of Iron. 

(35% of Ferric Chlorid and must be 
at least one year old.) 

Jalap. 

Powdered Jalap. (Contains 8% Resin.) 

Hydragog cathartic and diuretic 

Lactic Acid. See Acid, Lactic. 
Liquorice. 

Compound Liquorice Mixture. (Brown 
Mixture — 12% Paregoric.) 
Sedative expectorant mixture. 
Given at two-hour intervals 

Compound Liquorice Powder. 

Laxative 

Magnesium. 

Magnesium Carbonate. 

Antacid and laxative 

Magnesium Citrate, Solution of. (Liq- 
uor Magnesii Citratis.) 

Laxative. For one dose 

Magnesium Oxid. (Calcined Magnesia.) 

Antacid and laxative 

Magnesium Sulphate. (Epsom Salt.) 
Laxative. To be given every two 
hours and discontinued when the de- 
sired effect has been produced 



Dose. 



6 Months. 18 Months. 3 Years. 5 Years. 



gt. i-1 



gtt. 5 



gtt. 3 



gt. 1 



gtt. 15 



gr. 10 



gr. 5-10 



gr. 5-10 



gr. 10-15 



gtt. 1-2 



gtt. 10 



gtt. 6 



gtt. 3 



gtt. 20 



rr. 10- 
20 



gr. 20 



gr. 10- 
20 



gr. 20 



gtt. 3 



3i 

gtt. 15- 
20 

gr. 1-2 

gtt. 10 



gtt. 5 



gr. 2 



gtt. 30- 
40 



gr. 30 



gr. 30- 
40 



§2 

gr. 20- 
30 



gr 



. 20-30 



gtt. 3-5 



31 

gtt. 20- 
30 

gr. 2-3 

gtt. 20- 
30 



gtt. 10- 
15 



gr. 3 



gtt. 40- 
31 

gr.40- 
31 



gr. 40- 
31 



52-4 

gr. 30- 
40 



3f 



FOR INTERNAL USE 



583 



DRUGS AXD DRUG DOSAGE— FOR INTERNAL VSZ— {Continued) 



Drug. 



Dose. 



6 Months. 



Male-ferx. See Aspidium. 
Mentha Piperita. See Peppermint. 
Mentha Viridis. See Spearmint. 
Mercury. 

Mass of Mercury. (Blue Mass — 2>5% 
Mercury.) 
Cathartic and antisyphilitic. 

Used once a day 

Corrosive Chlorid of Mercury. (Bichlo- 
rid of ^lercury or Corrosive Sub- 
limate.) 
Antisyphilitic. 

Given three times a day 

Mild Chlorid of Mercury. (Calomel.) 
Cathartic, cholagog, antisyphilitic. 

At 30-minute intervals 

At one-hour intervals 

Rarely necessary to give more than 
one grain for laxative effect. 
Red lodid of Mercury. (Biniodid.) 
Antisyphilitic. 

Given three times a day 

Mercury with Chalk. (Gray Powder.) 

cholasfosf, and 



gr. 



gr- 



gr- 



gr. 



Intestinal antiseptic, 
antisyphilitic. 

At one-hour intervals — total gr. 1 . . . 

At one-hour intervals — total gr. 2 . . . 

Meth^x Salicylate. See under Acid, 

Salicylic. 
MiNDERERUS, Spirits of. See under 

Armnonium. 
MoRPHiN. See under Opium. 
Myrrh. 

Tincture of Myrrh (20^). 

Used as a mouth-wash diluted with 
water. 
Niter. See under Ether, Sweet Spirits of 

Niter. 
Nitroglycerin. (Glonoin, Glyceryl Tri- 
nitrate.) 

Vaso-dilator 

Spirits of Glyceryl Trinitrate, or Spirits 
of Glonoin,' old U. S. P. (1% , 

alcohoUc solution.) ^ gt. i 

Nux Vomica. (From Strychnos Nux 
Vomica.) 
Tincture of Xux Vomica (1^ Strych- 
nin). 

Stomachic and stimulant at 

Strychnin. (Alkaloid of Nux Vomica.) 
General stimulant, well borne by 
children. 

Every two or three hours gr. ^q- 



18 Months. 3 Years. 5 Years. 



gr. 



gr. i 



gr 



gt. i 



srt. 1 



gr. 1 



gr. i 



gr. -h 



gr. i 



gr. 



gr. 2U 



St. h 



Sftt. 1-2 



gr. Tw 



gr. 1-2 

gr.yV 
gr.'i 



gr.i 



:t. 1 



Stt. 2-4 



gr-ii^ 



584 DRUGS AND DRUG DOSAGE 

DRUGS AND DRUG DOSAGE— FOR INTERNAL VS^— (Continued) 



Drug 



Oleum Gaultherium. (Oil of Win- 
ter-green.) See under Acid, Sal- 
icylic. 

Oleum Morrhu^E. See Cod-liver Oil. 

Oleum Oliv^. See Olive Oil. 

Oleum Ricini. See Castor Oil. 

Olive Oil. 

Laxative and nutrient 

Used at night by rectum for the 

cure of constipation 

Opium. 

Sedative, anodyne, hypnotic. 
Tincture of Deodorized Opium (10%). 

Used in 3- to 10-drop doses in ene- 
mata as a sedative for children under 
five years of age. 

Camphorated Tincture of Opium. (Par- 
egoric — 0.4% Opium.) 

Sedative and analgesic 

Powder of Ipecac and Opium. (Dover's 
Powder — 10% each of Ipecac and 
Opium.) 

Sedative 

Morphin. (Alkaloid of Opium.) 

Not well borne by children and best 

given hypodermatically 

Codein. (Methylmorphin.) 

As sulphate or phosphate 

Heroin. (Diacetylmorphin.) 
As hydrochlorid. 

Bronchial sedative 

Orange-juice. (Citrus Aurantium.) 

Antiscorbutic 

Ox-gall. (Fel Bovis — Fresh Ox-bile.) 
Used as a laxative in enemata — 
3^-51 to a pint of water. 
Paregoric. Camphorated Tincture of 

Opium. See under Opium. 
PEpo. See Pumpkin Seed. 
Peppermint. 

Aqua Mentha Piperitce — Peppermint 
Water. (0.2% Oil of Pepper- 
mint.) 
Carminative, sedative, corrective and 

vehicle 

Pepsin. 

Powdered Pepsin 

Essence of Pepsin 

PhenacETin. (Acetphenetidin.) 

Antipyretic and analgesic 

Phosphoric Acid. See Acid, Phos- 
phoric. 



Dose. 



Months. 18 Months. 3 Years. 5 Y ears 



gtt. 15 



Si 



gtt. 3-5 



gr. t-t 



gr- T^ 



oh 



51 

gr. 1 
gtt. 20 



gr- i 



gtt. 15- 
30 

oli 



gtt. 10 



gr. 



gr- T¥o 



gr- 



0I-2 

gr- 1-2 

gtt. 30- 

40 

gr. 1 



gtt. 30- 
31 

52 



gtt. 15- 
20 



gr. 1-1 



gr- 5-0 



gr. TO 



gr. 5V 



33 

gr. 2-3 
gtt. 40- 
31 

gr. H 



53 



gtt. 20- 
30 



gr. 2-3 



gr. 2V 
gr-i 



51 



34 

gr. 3 
31 



gr- 



FOR INTERNAL USE 585 

DRUGS AND DRUG DOSAGE— FOR INTERNAL VS^— (Continued) 



Drug. 



Phosphorus. 

Oleum Phosphoratum ( 1 % in Almond Oil) 

Alterative 

Syrup of Hypophosphites. 

(Calcium 4.5%, Sodium and Potas- 
sium each 1.5%.) 

PHvOCARPIN. 

Not advised in the treatment of 
children. 
Potassium. 

Potassium Acetate. 

Diuretic, refrigerant, and alterative . . 
Potassium. Bicarbofiate. 

Should not be given to children on 
account of its disagreeable taste. 
Potassium Bitartrate. (Cream of Tar- 
tar.) See under Acid, Tartaric. 
Potassium Bromid. See under Bromin. 
Potassium Citrate. 

Diaphoretic and diuretic. 

Used in acute bronchitis 

Potassium Chlorate. 

Astringent and antisialogog. 

Used in stomatitis of every type, 

in tonsillitis and angina 

Potassium lodid. 

Antispasmodic and antisyphilitic . . 
Potassium and Sodium Tartrate. 
(Rochelle Salt.) See under Acid, 
Tartaric. 
Prunus Virginiana. See Wild Cherry. 
Pumpkin Seed. Pepo. 

Teniafuge. Best given in an emul- 
sion ; average dose 5 1 . 
Quassia. 

Infusion of Quassia. 

Vermifuge. 

An extemporaneous infusion is made 
by adding 1 or 2 oz. of Quassia chips 
to a pint of water. This is injected 
high up into the bowel. 

Used particularly to destroy the 
Oxyuris vermicularis. 
QuiNiN. (Alkaloid of Cinchona.) 

Bi sulphate of Quinin 

Sulphate of Quinin 

Tincture of Cinchoita 

All these are bitter tonics and 
antiperiodics. 
Rhamnus Purshiana. See Cascara Sa- 

grada. 
Rhubarb. 

Powdered Rhubarb. 

Laxative 



Dose. 



6 Months. 18 Months. 3 Years. | 5 Years 



gt. 



3J 



gr. 1-2 



gr. i-1 



gr. * 



rr. 1 



gr. 1-2 



gt. 1 



gr. 2-3 



gr. 1-2 

gr. 1 
gr. 1-2 



gtt. H 

31 

ST. 3 



gr. 1-2 
gr. 1-2 
gtt. 5-10 



gr. 2-3 



gr. 3 

gr. 2-3 
s:r. 2-3 



gr. 2-3 
gr. 2-3 
gtt. 15 



gtt. 2-4 
51-2 

gr. 5 



gr. 4 

gr. 3 
gr. 3 



gr. 3-4 

gr. 3-4 

gtt. 20- 

30 



gr. 3-4 ; gr. 5 



586 DRUGS AND DRUG DOSAGE 

DRUGS AND DRUG DOSAGE— FOR INTERNAL VS^— (Continued) 



Drug. 



Rhubarb (Continued). 

Aromatic Syrup of Rhubarb. 

Laxative and flavoring medium 

Mixture of Rhubarb and Soda. 

Corrective and laxative. 
I^. Pulveris rhei 

Sodii bicarbonatis aa gr. 48 

Syrupi rhei aromatici § 1 

Aquae q. s. ad o 2 

M. 

Sig. — One to three doses daily 

RoCHELLE SaIvT. See under Acid, Tar- 
taric. 
Saccharin. (Benzosulphinidum.) 

Substitute for sugar, but 200 times 
sweeter. 

For 8 oz. of food, J-1 grain is suffi- 
cient. 
Saccharose. See Sugar. 
SaIvICYIvIC Acid. See Acid, Salicylic. 
Salol. See under Acid, Salicylic. 
Santonin. (Anhydrid of Santoninic 
Acid.) 
Vermifuge, for round-worms partic- 
ularly 

Senna. 

Cathartic. Best given as Compound 
Liquorice Powder, of which it is an 
ingredient, q. v. 
Serum Antidiphtheriticum. (Diph- 
theria Antitoxin.) 
For immunization: 

1000 to 2000 units. 
In f aucial diphtheria : 

3000 to 5000 units and repeat in 
8 hours if required. 
In laryngeal diphtheria : 

5000 units and repeat in 8 hours if 
required. 

The repetition of the doses of 
Antitoxin is discontinued only 
when the case ceases to require the 
serum. 

The dosage is independent of the 
age of the patient. 
S0DIU.M. 

Sodium Benzoate. 

Antiseptic, antipyretic, and anti- 
rheumatic. 

Used in cystitis with alkaline fermen- 
tation to acidify the urine, which it 
does by the liberation of hippuric 

acid 

Sodium Bicarbonate. 

Antacid, antirheumatic 



Dose. 



6 Months. 18 Months. 3 Years. 5 Years 



51 



^t 



gr. i 



gr. 1 
gr. 1-2 



52 



52 



gr. 1 



gr. 1-2 
gr. 2 



53 



o3 



gr. 1-2 



gr. 2 
gr. 3 



34 



34 



gr. 2 



gr. 3 
gr. 5 



FOR INTERNAL USE 587 

DRUGS AND DRUG DOSAGE— FOR INTERNAL VS^— (Continued) 



Drug. 



Sodium (Continued). 

Sodium Borate. (Borax.) 

Antiseptic and astringent. 

Used as a gargle and mouth-wash 
in angina and stomatitis — ol to §8 
of water. 

Sodium Bromid. See under Bromin. 
Sodium lodid. 

Uses and doses the same as Potas- 
sium lodid, q. V. 
Sodium, Phosphate. 

Laxative and cholagog 

Sodium, Sulphate. (Glauber's Salt.) 

Cathartic. 

Used in intestinal infection of inac- 
tive type 



Sodium Salicylate. See under Acid, 
Salicylic. 
Spearmint. (Mentha Viridis.) 

Water of Spearmint. (Aqua Menthge 

Viridis--0.2% Oil of Spearmint.) 

Carminative, sedative, corrective, 

and vehicle 

Strontium. 

Strontium Bromid. See under Bromin. 
Strophanthus. 

Tincture of Strophanthus (11% in New- 
Pharmacopeia, or twice former 
strength) . 
Cardiac tonic and diuretic. Pre- 
ferred to Digitalis in the treatment of 

children because better borne 

Strychnin. See under Nux Vomica. 
Sugar. (Cane-sugar or Saccharose.) 
Sweetening agent. May be substi- 
tuted for Lactose in the adaptation 
of cow's milk for infant-feeding. 
1 level tablespoonful equals J oz. 
Sugar of Mii^k. (Lactose.) 

Used as an excipient and in the 
adaptation of cow's milk for infant- 
feeding. 

1 level tablespoonful equals \ oz, 

SuiyPHONAL. 

Not advised in the treatment of 
children. 
Sulphur. 

Precipitated Sulphur, or Milk of Sul- 
phur. 

Laxative and alterative. Given usu- 
ally in syrups or other heavy vehicles . . 

Used also as a reducing agent in 
Bismuth mixtures when the stools do 
not become dark colored (see p. 213) ... . 



Dose. 



6 Months. 18 Months. 3 Years. 5 Years 



gr. 5-10 



gr. 15- 
30 



31 



gt. 1 



gr. 5 
gr. 1 



gr. 10-15 



gr. 30- 

45 



gtt. 1-2 



gr. 5-10 
gr. 1 



gr. 15-20;gr. 20-30 



gr. 40- 
51 



33 



gtt. 2 



gr. 15-30 
gr. 1 



31 



34 



gtt. 2-3 



31 

gr. 1 



588 DRUGS AND DRUG DOSAGE 

DRUGS AND DRUG DOSAGE— FOR INTERNAL VSn—{Continv£d) 



Drug. 



Tannai^bin. See under Acid, Tannic. 
Tannigen. See under Acid, Tannic. 
Tartar Emetic. See under Acid, Tar- 
taric. 
Tartaric Acid. See Acid, Tartaric. 

Terebene. 

Stimulating expectorant and anti- 
septic 

Terpin Hydrate. 

Expectorant and antiseptic. 
Used in subacute and chronic bron- 
chitis 

TrionaIv. 

Not advised in the treatment of 
children. 
Urotropin. (Trade name for Hexame- 
thylenamine.) 

Urinary antiseptic and sedative 

Whisky. See under Alcohol. 
Wild Cherry. 

Syrup of Wild Cherry. (Syrupus 
Pruni Virginiani.) 
Bronchial sedative and vehicle. 
Contains Hydrocyanic Acid 



Dose. 



Months. 18 Months. 3 Years. 5 Years, 



gt. 1 



gr. 1 



gtt. 1-2 
gr. i 

gr. 1-2 
5i 



gtt. 2 
gr.i 

gr. 2-5 

31 



DRUGS FOR EXTERNAL USE 
Acid, Boric. 

Antiseptic of mild grade. 4% is a saturated solution. 

Used both in solution and in ointments. 

In the form of scales it is most soluble and most convenient. 
Acid, Carbolic. See Phenol. 
Acid, Chromic. (Chromic Trioxid.) 

A very strong caustic and astringent, used as a substitute for Nitrate 
of Silver. 
Acid, Nitric (68% pure acid). 

Used as a caustic. 
Acid, Salicylic. 

Used in lotions or in ointments, 1% to 3%, for skin affections. 
Acid, Tannic. 

Astringent. 

Used in 1% solution in dysentery; as an ingredient of suppositories for 
hemorrhoids. See also Glycerite of Tannin under Glycerin. 
Adrenalin. (Trade name for the active principle of the Adrenal Gland.) 

Used in a solution in the strength of 1 part to 1000 of normal saline solution 
or sterilized oil. 

Local hemostatic and astringent. It will render bloodless the field of opera- 
tion of the eye, nose, and throat, but its use is often followed by hemorrhage. 
Aluminium Acetate, Solution of. 

Antiseptic dressing for cellulitis, abscesses, etc. 

1. I^. Aluminii sulphatis 53^ 

Acidi acetici p4^ 

Aquae §10 

2. I^. Calcii carbonatis o H 

Aquae §2^ 

Add 1 to 2, stirring. 



DRUGS FOR EXTERNAL USE 589 

Amylum. See Starch. 
Argentum. See Silver. 
Argyrol. See Silver. 
Aristol. (Thymol Di-iodid.) 

Mild antiseptic, used as a dusting-powder or in ointments. 
Balsam of Peru. 

A stimulating dressing for wounds and ulcers. 

In Castor Oil, one part of the Balsam to six of the oil, it makes a useful 
application for burns and wounds. 
Benzoin. 

Compound Tincture of Benzoin. 

Used as a bronchial sedative in steam inhalations, one-half ounce to 
two pints of water. 
BiCHLORiD OF Mercury. See under Mercury. 
Bismuth Subgallate. (Dermatol.) 

Used externally as a drying antiseptic powder, either pure or in com- 
bination. Also as an ingredient of ointments of 10% to 20% strength. 
BoRACic Acid. See Acid, Boric. 
Cacao-butter. (Oleum Theobromatis.) 

A fixed oil expressed from the seeds of the Theobroma Cacao. Melts 
at 30°-35° C. (86°-95° F.). 

Used as an emollient and as a base for suppositories. It may be used 
for nutrient inunctions, but it is less effective than Goose Oil. 
Calamine. (Zinc Carbonate.) 

Used as an ingredient of soothing lotions in itching affections of the 
skin — eczema, urticaria, dermatitis venenata, etc. 
Calomel. See under Mercury. 
Cantharides. 

Vesicant. Used best in the form of Collodion of Cantharides, q. v. 
Carron Oil. (Limentum Calcis.) 

Consists of equal parts of Lime-water and Linseed Oil. 
Used as a soothing application for burns and scalds. 
Chloroform. 

Locally a rubefacient and, when confined, a vesicant as well. A useful 
ingredient of liniments. 

By inhalation, a general anesthetic. 
Chrysarobin. 

Used in 5% ointment for psoriasis and tinea tonsurans. 
Cocain. 

Alkaloid obtained from several varieties of Coca. 

A local anesthetic when applied to wounds or mucous surfaces or when 
injected hypodermically. 

For local application, 3% to 10% solutions. 
For hypodermic use, 0.2% to 4% solutions. 
CoD-LivER Oil. 

May be used locally as a nutrient inunction, but its odor is objection- 
able. 
Collodion. 

Solution of Pyroxylin in Alcohol and Ether. 
Collodion of Cantharides (60% Cantharides). An excellent blistering 

agent. 
Collodion of Ichthyol (10%-20%). Used to cover the wound after aspir- 
ations or lumbar punctures, and in checking the spread of erysipelas. 
Collodion of Iodoform (5%). Used in erysipelas. 
Collodion of Oil of Cade (l%-5%). Used in eczema. 

Collodion of Salicylic Acid (10%). Used in removing corns and callouses. 
Creosote. 

Used in inhalations as a pulmonary antiseptic. 
Dermatol. See Bismuth Subgallate. 
Bucain. 

Beta-eucain. Local anesthetic with similar action and uses to Cocain, 
but without its toxicity. Its solutions can be sterilized without injury 
by boiling. 



590 DRUGS AND DRUG DOSAGE 

FORMALDEHYD. 

Antiseptic and deodorant. 

Used in solutions of from 0.5% to 2% strength, as an antiseptic. 

Used in the form of the gas for disinfecting, the gas being generated 
by heat, from solutions, or from the solid, Paraform. 
G1.YCKRIN. 

Used chiefly as a solvent or excipient. Very hygroscopic. It is the 
base of the Glycerites. 

Glycerite of Carbolic Acid — 20% Phenol in Glycerin. An external anti- 
septic and antipruritic. 
Glycerite of Starch — 10%. A vehicle for skin preparations and for pills. 
Goose Oil. 

The oil tried from the goose. An excellent oil for nutrient inunctions. 
It is better than Olive Oil or Cacao-butter, for being an animal oil it is 
more readily absorbed by the skin. It is semifluid, has a low melting- 
point, and does not become hard after having been rubbed in. 
Grindelia Robusta. 

The fluidextract, in the strength of one dram to a pint of water, is used 
as a wet dressing in dermatitis venenata. 

GUAIACOL. 

Combined with equal parts of Glycerin, it is used in acute joint affec- 
tions, for its analgesic effect. 
HamamELIS. See Witch-hazel. 
Hydrargyrum. See Mercury. 
Hydrogen Peroxid. 

Antiseptic and deodorizer. Used in 10-volume, 3% solution to clean 
wounds, and to dissolve and destroy pus. 

ICHTHYOE. 

Used in 1% solution in intertrigo. 

Used in 5% to 50% solutions in skin diseases or in erysipelas. 
Used in 5% to 50% ointments in skin diseases or in erysipelas. 
Used suspended in oil in strength of 5% to 25% as a nasal spray. 
Iodin. 

Tincture of I odin {1%). 

Antiseptic and counter-irritant. 

Used particularly in tinea tonsurans and tinea circinata. 
Iodoform. Formyl Tri-iodid. 
Antiseptic and alterative. 

Used in the form of a powder, an ointment, or on gauze in the strength 
of 5% to 10%. 
Kaolin. 

Cataplasma Kaolini. 

A smooth homogeneous mass consisting of Kaolin, Boric Acid, Thymol, 
Methyl Sahcylate, Oil of Peppermint, and Glycerin. 
Lanolin. 

Used as an ointment base. 
Lead and Opium Wash. 
Anodyne lotion. 

I^. Liquoris plumbi subacetatis §iv 

Tincturae opii § j 

Aquae Bxvj 

Fiat mistura. 
Sig. — Use externally. 
Menthol. (Peppermint Camphor.) 

Sedative, analgesic, refrigerant, and antipruritic. 
Used in ointments, 1% to 5%. 
Used in oily solutions, 1% to 5%. 

Used triturated with equal parts of Camphor as an anodyne. 
Mercury. 

Bichlorid of Mercury. 

Antiseptic. Used in 1:1000 to 1:20,000 solutions. 
Calomel. 

A milder antiseptic than the foregoing. Used as a dustmg-powder m 
eye affections and in the lesions of secondary syphiHs. 



DRUGS FOR KXTKRNAI^ USE 591 

Mercury and Ammonium Chlorid. (White Precipitate.) 

Used in ointments of \% to 10% strength as an antiparasitic and anti- 
syphiHtic. Of particular value in impetigo contagiosa, ringworm, etc. 
Yellow Oxid of Mercury. 

Antiseptic. Used in ointments of 0,5% to 10% strength in ophthalmia. 
Of value also in ringworm and syphilitic eruptions. 
Mustard. 

Counter-irritant. 

In the form of papers (chartce) for local pain or vomiting. 

In the form of powder: 

In pastes of a strength of 1 part of mustard to from 2 to 6 parts of flour. 
In baths — 1 tablespoonful to 6 gallons of water. 
In packs, in the same proportion. 
Oil op Cade. (Oil of Juniper Tar.) 

Used as an antiparasitic in skin diseases. 
In powders, 1% to 5% in a base of Stearate of Zinc. 
In ointments, 1% to 5%. 
In Collodion, 1% to 5%. 
On. OF Turpentine. (Spirits of Turpentine.) 
Rubefacient and counter-irritant. 
Used as an ingredient of liniments. 

Used in the form of turpentine stupes for the relief of abdominal distention. 
Flannel cloths are wrung out in hot water to each pint of which gtt. 10-20 of 
Oil of Turpentine have been added, and are then applied to the abdomen. 
Olive Oil. 

Used externally as a nutrient inunction. 
Petrolatum (Petroleum Jelly or "VaseHn"). 

Used as a base for ointments. 
Phenol. (Pharmacopeial name of Carbolic Acid.) 
Local anesthetic and antiseptic. 

Used as an antiseptic in solutions of the strength of 5% or less. 
Used as a caustic and local anesthetic in strength of 95%. 
Children are very susceptible to Phenol poisoning. 
Pix Liquida. See Tar. 
Potassium Permanganate. 

Antiseptic and disinfectant. 

Used in solutions in the strength of 1 : 4000 to 1 : 2000 on mucous sur- 
faces, and in the strength of 1 : 1 000 on ulcers and superficial wounds. 
Resorcin. 

Antiseptic in skin diseases, particularly in seborrheic eczema. 
Lotions, 1% to 5%. 
Ointments, 1% to 5%. 
Silver. 

Silver Nitrate. Antiseptic and astringent. Used in solutions of 1% to 

50% strength. As a caustic, it is used in the solid form. 
Argyrol. (Silver Vitellin — Proprietary.) 

A mild antiseptic, not approaching the Nitrate in eflficacy. Used in 
solutions of 5% to 50% strength or in ointments of 5% to 50% strength. 
Sodium Bicarbonate. 

Used in saturated solution as an antipruritic and as an analgesic in skin 
diseases and burns. 
Starch. 

Used as the base of drying-powders. 
Sulphur. 

In 5% to 55% ointments as a parasiticide, particularly in scabies. 
Tar. (Pix Liquida.) 

Antiseptic. Used in skin diseases as the officinal ointment (50%) or 
in ointments with other ingredients. 
Zinc Oxid. 

Used as a 20% ointment in Benzoinated Lard, in skin diseases, such 
as eczema, needing a mild astringent. 

Used in dusting-powders in the strength of 5% to 10%. 
Official Zinc Ointment makes a good base for stronger antiseptics, such 
as Tar and Oil of Cade. 



NDEX 



Abdominal distention as sign of peri- 
tonitis, 491 
in chronic ileocolitis, 216 
in inactive enteric infection, 209 
massage in constipation, iS6 
Abscess, ischiorectal, 230 
of breast, 53 

peritonsillar, incision of, 252 
situations of, 252 
treatment of, 253 
retropharyngeal, 254, 258 
breathing in, 255 
examination of throat in, 255 
incision of, 257 
position of head in, 255 
treatment of dysphagia in, 257 
Absorption of saline solution in colon 

irrigation, 221 
Acarus scabiei, 435 
Acetone, absence of, in glycosuria, 

366 
Acne, vaccine therapy in, 530 
Aconite, tincture of, in fever, 498 
in nephritis, 359 
in pericarditis, 303 
in pleurisy, 292 
Acute illness, essentials in care of, 166. 

See also Illness, acute. 
Adams' position, 552 
Adapted milk, 105 

Adenitis, acute, treatment of, 446, 447 
cervical, confused with mumps, 348 
in diphtheria, 316 
in scarlet fever, 333 
from pediculi capitis, 446 
persistent, 447 
retropharyngeal, 119, 451 
suppurative, 254 
tubercular, treatment of, 452 
vaccine therapy in, 530 
Adenoids, 448 

as cause of cough, 268, 338 
of incontinence of urine, 352 
of laryngeal croup, 259 
of nasal catarrh, 244 

hemorrhage, 246 
of otitis, 440 

of persistent deafness, 444 
associated with asthma, 276 
cough of, 448 
crushing of, 449 
deterrent to growth, 149 

38 



Adenoids in chronic otitis media, 445 
in epileptics, 389 
in laryngismus stridulus, 264 
in night-terrors, 380 
mouth-breathing due to, 448 
occurrence of, 448 
operation for, 449 
removal of, for chronic bronchitis, 

274 
return of, after operation, 451 
treatment of, 449 
without mouth-breathing, 244 
Adherent pleura as cause of persist- 
ent cough, 268, 269 
Adhesive plaster strapping in pleu- 
risy, 292 
in umbilical hernia, 416 
in ventral hernia, 417 
Adirondacks good for older children, 

523 
Adrenalin in hemorrhagic diseases of 
the newly born, 54 
in nasal hemorrhage, 236 
Afternoon nap, 27, 28 
Agglutinins, 527 

Airing nursery and sleeping-room, 60 
Air-cushion in decubitus, 436 
Air-space necessary in nursery, 24 
Albolene inunctions in measles, 345 
in rhinitis, 242 
spray in scarlet fever, 332 
Albuminuria, 356 

clothing in a case of, 357 
cyclic, 356 
diet in a case of, 357 
dietetic, 356 

examination of urine in, 357 
febrile, 356 
laxatives in, 357 
management of cases, 357 
paroxysmal, 356 
transient, 356 
Albumin-water, formula for preparing, 

129 
Alcohol, abuse of, 313 
administration of, 525 

by rectum, hypodermatically, etc., 
520 
and mother's milk, 75 
and water, bath of, 30 
for sponging, 502 
in noma, 237 

593 



594 



INDEX 



Alcohol as cause of cerebral palsy, 433 
of delicate children, 155 
of multiple neuritis, 401 

as drug, not a beverage, 519 

as food during illness, 139 

for nipples, 236 

habit easily acquired in chronic 
ileocolitis, 217 

in bronchopneumonia, 284, 285 

in collapse, 520 

in diphtheria, 324, 519 

in gastro-intestinal infection, 202 

in lobar pneumonia, 290 

in neurotic children, 380 

in prevention of decubitus, 436 

in purpura, 472 

in scarlet fever, 332, 519 

in severe toxemia, 519 

in typhoid fever, 483, 520 

in vomiting, 203 

irritant to the kidneys, 519 

narcosis, gavage in, 143 

physiologic action, 519 

to increase fat in breast-milk, 178 

tolerance for, 519 

used harmfully, 19, 519 

when to give, 519 
Alderney cream, 1 1 1 
Alkalies in the adaptation of cow's 

milk proteid, 106 
Aloes, tincture of, in finger sucking, 

454 
Alternating use of drugs in cystitis, 

367 
Alum in pertussis, 339 
Ammonium salts, administration of, 

525 

for children, 283 

in bronchitis, 273 

in lobar pneumonia, 291 

interfering with digestion, 19 

unpalatable, 525 
Anemias of infancy, 460 

bathing in, 460 

country living in, 460 

fresh air in, 460 

in cardiac disease, 312 

intestinal toxemia a cause of, 460 

lack of appetite a cause of, 131 
Anesthetics, gas-ether sequence, 517 
in children, 516 
use of, in thoracotomy, 295 
Angina, recurrent, 245 

associated with cardiac disease, 
310 
Angioneurotic edema, 407 
Antacids in milk adaptation, 106 
Anterior poliomyelitis, 398 

exercises for, 571 
Antibodies, 527 
Antipyretic drugs for fever, 498 

in lobar pneumonia, 289 

in typhoid fever, 481 



Antipyrin, 278 

as an antipyretic, 499 
as cause of purpura, 471 

of urticaria, 430 
in catarrhal laryngitis, 263 
in laryngismus, 265 
in nasal hemorrhage, 246 
with sodium bromid in pertussis, 341 
Antirheumatic treatment in peliosis 
rheumatica, 490 
in tonsillitis, 252 
Antispasmodic treatment in catarrhal 

croup, 261, 262 
Antitetanic serum, 56 
Antitoxin, diphtheritic, 316 

administration of, 316, 318 
amount necessary, 317, 318 
as cause of urticaria, 430 
dosage for immunization, 322 

for laryngeal diphtheria, 317 
effect on blood, 321 
in cervical adenitis, 447 
in doubtful cases of diphtheria, 

.249 

in laryngeal diphtheria, 328 
in nasal catarrh, 345 
in rhinitis, chronic, 345 
in suspicious throats, 250 
late in diphtheria, 320 
repetition of, 318 
site of injection, 322 
when and how to use, 317 
rash, percentage of occurrence, 321 
Antrum, suppration of, vaccine therapy 

in, 530 
Anus, inflammation of, 225 

prolapse of, 228 
Aortic disease, conduct of life in, 311 
Aphthae, Bednar's, 237 
Appendicitis, 222, 223 
Appetite, habitual loss of, 131 

poor, due to fissures of lips, 238 
to too frequent feeding, 131 
Apple, baked, when allowed, 136 

raw, when allowed, 137 
for constipation, 174 

sauce, when allowed, 136 

scraped, in constipation, 183 
Aristol collodion for lumbar punc- 
ture holes, 391 
to cover needle holes, 373 
Arizona in tuberculosis, 523 
Arnold steam atomizer, 342 

sterilizer, 1 1 5 
Arsenic as cause of urticaria, 430 

in cardiac disease, 312 

in chlorosis, 463 

in chorea, 386 

in diabetes, 366 

in habit spasm, 388 

in hysteria, 379 

schedule in chorea, 386 

signs of overdose, 387 



INDEX 



595 



Arsenical multiple neuritis, 401 

Arthritis in scarlatina, 335 

Articular rheumatism, chloroform 

liniment in, 516 
Artificial feeding, 82 

respiration in asphyxia of newly 
born, 48 
Dew's method, 48 
Laborde's method, 48 
Schultze's method, 48 
Ascaris lumbricoides, 226 
Asparagus, when allowed, 136 
Asphyxia in the newly born, 48 
Asphyxiation from nitrous oxid, 417 
Aspidium, oleoresin of, in tapeworm, 

228 
Aspiration of carbolic acid into larynx, 
266 
of hydrocele, 372 
of pericardium, 304 
Aspirin in chorea, 385 
in cyclic vomiting, 495 
in endocarditis, 306 
in habit spasm, 388 
in pericarditis, 304 
in recurrent bronchitis, 275, 278 
in rheumatism, 489 
Asthma associated with cardiac dis- 
ease, 310 
bicarbonate of soda in, 279 
bowel function in, 279 
drugs in, 278-280 

due to irritation by pollen of plants, 
276 
to lithemic diathesis, 276 
to rheumatism, 487 
in recurrent bronchitis, 276, 277 
inhalations in, 279 
red meat in, 279 

rheumatic inheritance in, 276, 277 
salicylate of soda in, 280 
Astringents in diarrhea, 205 
Ataxia, congenital, exercises for, 542, 
■ 556 

Atelectasis, 51 
death from, 51 

due to compression of fluid, 51 
Athrepsia. See Marasmus. 
Atlantic City after grippe, 476 

for convalescents, 522 
Atropin in incontinence of urine, 354 
in night -sweats, 301 
with morphin, 203 
Axillary temperature, 497 



Babcock milk test, 92 
Babies' Hospital Dispensary, percent- 
age of normal development in 
children, 58 
rules for feeding children, 103 
Baby basket, 19 
clothes, 20 



Baby, condition of, best guide to wet- 
nurse, 81 
Bacillus coli communis, vaccine 
therapy, 531 
Klebs-Loffler, causing chronic nasal 
discharge, 244 
diphtheria, 316, 317 
lactic acid, action on milk, 120 

treatment of acute intestinal 
infections, 2 1 1 
pseudodiphtheria, vaccine therapy, 

531 
Backward children often deaf, 444 

with adenoids, etc., 444 
Bacterial examination for diphtheria, 

317 
of vaginal discharge before dis- 
charge of patient, 375 
Baked flours, 125 
Balanitis, treatment of, 370 
Balsam of Peru for sluggish granula- 
tions, 230 
Barley gruel, when allowed, 135 
jelly, formula for preparing, 129 
water after gastro-intestinal infec- 
tion, 203 
before nursing, 75 
formulae for preparing, 129 
in acute ileocolitis, 212 
in diarrhea, 172 
Basket for baby's toilet, 19 

for early exercise, 25 
Bassorin paste in eczema, 423 
Bathing, 60 
after meals, 30 
in illness, 60 
of delicate children, 154 
necessity of daily, 152 
of premature infant, 45 
Bath-room, temperature of, 29, 505 
Baths, alternate hot and cold, 265 
and meals, 30 
brine, 31 
cool, 29 

during illness, 505 
hot, 31 

in anemia, 461 

in chronic diffuse nephritis, 362 
in furunculosis, 435 
in lobar pneumonia, 289 
in typhoid fever, 478 
mustard, 30 
overcoming fear of, 29 
reaction after, 30 
soda, 31 
starch, 31 

temperature, for fever, 30 
for one year old, 29 
for very young, 29 
time for daily, 30 
tub, 29, 30 
varieties, basin, 30 
bran, 31 



596 



INDEX 



Beans, dried, in dietary of delicate 

children, 167 
Bednar's aphthae, 237 
Bed-clothing, care of, in quarantine, 

318 
Bed-sores, 435 
Bed-time, 43 
Bed-wetting. See Incontinence of 

urine. 
Beef broth, formula for preparing, 1 29 
foods, 124 
juice, formula for preparing, 129 

in marasmus, 162 
scraped, formula for preparing, 129 
Beer after sixth year, 138 
Belladonna, extract of, 71 
in constipation, 175 
in epilepsy, 390 
in pertussis, 340 
in rhinitis, 241 
Bicarbonate of soda in asthma, 278, 
279 
in bath, 31 
in bronchitis, recurrent, 274, 275, 

278 
in cardiac disease, 310 
in chorea, 385 
in cyclic vomiting, 495 
in eczema, 422 
in intertrigo, 424 
in persistent vomiting, 189 
in quinsy, 254 
in rheumatism, 486 
Bichlorid bath after quarantine, 316 
of mercury, administration of, 525 
an irritant drug, 525 
as ear irrigation, 443 
as wet dressing, 49 
for thread-worms, 228 
in anemia, 462 
in balanitis, 370 
in congenital syphilis, 408-410 
in mastitis of young girls, 52 
in noma, 237 

in otitis media, chronic, 445 
in paraphimosis, 370 
in ringworm of the scalp, 437, 438 
in tardy malnutrition of syphil- 
itic origin, 413 
in tetanus, 56 
in typhoid excreta, 479 
Biedert, quoted, 334 
Binder for breasts, 78 
Bird's eye diapering, 20 
Bismuth mixture, 205 

subnitrate, impure, poisoning from, 
205 
in diarrhea, 205 

of scarlet fever, 481 
in dilatation of the stomach, 195 
in ileocolitis, 213 

with Dover's powder in fecal 
incontinence, 231 



Biting finger-nails, 454 
Bladder, irrigation of, in cystitis, 367 
non-development of, due to incon- 
tinence, 352 
stone in, 367 

weakness of sphincter of, in enure- 
sis, 352 
Bleeding from breast causing hema- 

temesis, 193 
Blindness, transitory, in pertussis, 337 
Blisters to spine in poliomyelitis, 399 
Blood-streaked stool due to fissure of 

anus, 225 
Boarding-schools for the cure of hys- 
teria, 378 
Body-heat, maintenance of, in prema- 
ture infants, 45 
Boiled milk a cause of constipation, 

182 
Boils, 434 

Bone, dead, a cause of chronic ear dis- 
charge, 445 
tuberculous disease of, 493 
Borax water for nipples, 23 

for rectal irrigation in worms, 228 
Boric acid in dusting-powder, 52 
insufflations in pertussis, 338 
ointment (10 per cent.) in cold 
cream, 347 
in contagious impetigo, 431 
in fissure of lips, 232 
in furunculosis, 434 
in ivy poisoning, 433 
in mammary abscess of infants, 

. ^^ . . 

in vaccination wounds, 508 

saturated solution of, 78 

in Bednar's aphthae, 238 

in care of nipples, 78 

in cleansing teeth, 35 

in gonorrheal vaginitis, 375 

in measles, 345 

in noma, 237 

in retropharyngeal adenitis, 

452 

in tonsillitis, 250 

mouth-wash of, 49 

wet dressing of, 49 

for vaccination ulcers, 

507 
Bottle-fed, constipation in, 180 
Bottle-feeding in breast-fed, 75 
Bowel function, 177 

defective, a cause of colic, 176 
in asthmatics, 279 
in epilepsy, 389 
in lobar pneumonia, 288 
in nephritis, 338 
in scarlet fever, 330 
in tubercular peritonitis, 492 
of intestinal intoxication, 177 
treatment of, 177 
in acute illness, 169 



INDKX 



597 



Bow-legs, rachitic, 466 
Boys, hysteria in, 377 
Braces after poliomyelitis, 399 
for bow-legs, 466 
for masturbation, 458 
to prevent contractures, 404 
Brachial plexus, injury to, during labor, 

406 
Brain lesion as cause of early convul- 
sions, 380 
Bran bath in eczema, 423 

in prickly heat, 439 
Brandy, 50, 202, 291, 519. See also 

Alcohol. 
Breast, abscess of, in infants, 53 
in newly born, 59 
bandaging, during weaning, 76 
binder for, 78, 79 
caking of, 79 

care of, during weaning, 76 
feeding in marantic infants, 158 
massage of, 79 
milk by gavage, 143 

in chronic ileocolitis, 217 
regulation of percentages in, 74, 75 
time of appearance of, 77 
pump, 79 
Breath of diphtheritic patient, 316 
Breathing, exercises for, 542-545 
Breck feeder in premature infants, 47 
Brine baths, 31, 144 

for neurotic children, 379 
in rickets, 465 
in tardy malnutrition, 165 
in tetany, 384 
with goose-oil rub, 465 
Bromid of soda, 263, 278 

in anterior poliomyelitis, 399 
in convulsions, 381 
in cough after intubation, 327 
in endocarditis, 305 
in epilepsy, 390 
in gyro-spasm, 383 
in hiccough, 407 
in hysteria, 380 
in laryngismus, 265 
in measles-cough, 346 
in meningitis, 391, 392 
in nephritis, 361 
in neuritis, 402 
in night-terrors, 382 
in persistent hematemesis, 196 
in pertussis, 340 
in polyuria, 366 
in tetanus neonatorum, 56 
in tetany, 384 
Bromoform in pertussis, 339 
Bronchiectasis, interstitial, 301 
Bronchitis as complication of influenza, 

475 
associated with bronchopneumonia, 
270 
with measles, 270 



Bronchitis associated with whooping- 
cough, 270 

duration of, 271 

fever range in, 270 

mustard paste in, 515 

periodic asthmatic, 277 

physical signs in, 270 

predisposing to bronchopneumonia, 
280 

recurrent, due to rheumatic habit, 
276, 277, 485 

respirations in, 271 

signs of developing bronchopneu- 
monia in, 270 

symptoms of, 270 

treatment of, 271-274 

varieties, 270 
Bronchopneumonia. See Pneumonia, 

broncho-. 
Broths after diarrhea, 206 

formulae for preparing beef, chicken, 
and mutton broth, 129 

in ileocolitis, 212 

in illness, 139 

in nephritis, 358 

nutriment of animal, 324 

when allowed, 135 
Buckwheat as cause of urticaria, 430 
Buhae of skin in pemphigus, 431 
Bunge, quoted, 461 
Butter in milk idiosyncrasy, 114 

to replace the fat of milk, 152 

when allowed, 135, 136 
Buttermilk, 120 

in typhoid fever, 479 
Button for umbilical hernia, 416 



Cacao-butter rub, 145 
Caffein in bronchopneumonia, 283 
in fever, 499 
in influenza, 474 
Caking of breasts, 79 
Calcium lactate in hemophilia, 473 
in purpura, 472 
in vomiting, 196 
California for nephritis cases, 522 
Calomel and rhubarb in pharyngitis, 248 
contraindicated in the cure of con- 
stipation, 184 
fumigations in catarrhal croup, 262 
in chronic eczema, 425 
in gastric indigestion, 189 
in ileocolitis, 213 

chronic, 218 
in influenza, 474 
in lobar pneumonia, 288 
in pleurisy, 292 
in tonsillitis, 250 
initial dose, in acute gastro-intestinal 

infection, 203 
vs. castor oil in acute gastro-intes- 
tinal infection, 203 



598 



INDEX 



Calorimetric standard, no 
Camphor as a counterirritant, 515 
as a heart stimulant, 290 
in hemorrhoids, 230 
in rhinitis, 243 
water in earache, 440 
Camphorated oil in mumps, 348 
Cancrum oris, treatment of, 236 
Candy in chorea, 385 
Canine teeth, time of appearance of, 36 
Cantharides, tincture of, 356 
Capsicum as a counterirritant, 515 
Capsules for unpalatable drugs, 526 
Carbohydrates, action of, on flora of 
intestine, 126 
essential ingredients of, 61 
function of, as foods, 62 
in diarrhea, 172 
where found, 61 
Carbolic acid in post-antitoxin urti- 
caria, 321 
in ringworm of the scalp, 437 
solution of, for bed-clothes, 315 
Cardiac disease, prognosis in, 311 
Care of bottles to prevent sprue, 236 
of breasts to prevent sprue, 235 
of milk on farm, 201 
of mouth to prevent sprue, 236 
Cascara sagrada, 71, 218 
in cardiac disease, 312 
in colic, 177 

in constipation, 175, 181, 184 
in hysteria, 379 
in scarlet fever, 330 
Casein, 62, 84, 106 

causing constipation, 180. See also 
Milk. 
Cases illustrative of abundant but too 
weak milk, 74 
of adenoids as a cause of persist- 
ent cough, 269 
of adherent pleura as a cause of 

persistent cough, 269 
of angioneurotic edema, 374 
of antipyretics in typhoid fever, 

481 
of iDcd wetting, 353 
of cerebral hemorrhage and palsy, 

404 
of chronic ileocolitis, 217 
of colon flushing, 518 
of cow's milk idiosyncrasy, 114 
of day terrors of intestinal origin, 

of death- from pericranial hemor- 
rhage in the newly born, 54 

of double empyema, 297 

of dysarthria from intestinal tox- 
emia, 174 

of eczema, 422 

of empyema after bronchopneu- 
monia, 297 

of empyema necessitatis, 298 



Cases illustrative of epilepsy, 390 
of erythema nodosum, 432 
of excessive feeding, 162 
of fatal grippe, 475 

laryngismus stridulus, 264 
of fatigue fever, 500 
of fecal impaction, 222 
of fissure of the anus, 225 
of gavage in malnutrition, 143 

in persistent vomiting, 141 
of hematemesis from blood in 

breast milk, 194 
of hemophilia, 472 
of history of marasmus, 158 
of hyperpyrexia from ulcerative 

stomatitis, 233 
of hysteria in the third generation, 

377 
of ileocolitis, 212 

of inactive type of intestinal infec- 
tion, 209 
of incubation period of pertussis, 
■ 336 
of intestinal obstruction due to 

Meckel's diverticulum, 222 
of intubation, 327 
of intussusception, 224 
of malignant endocarditis, 307 
of masturbation, 457 
of mildness of pertussis, 337 
of milk-giving in typhoid, 480 
of mucous colitis, 218 

phenomena of intestinal indiges- 
tion, 173 
of myocarditis, 309 
of nervous causes of vomiting, 187 
of night-terrors from overeating, 

382 
of oil treatment for constipation, 

186 
of otitis media, 441 
of overfeeding in nurslings, 74 
of peritonitis, general, 491 
of persistent glycosuria, 365 
of post-diphtheritic paralysis, 400 
of primary tuberculous pleurisy 

with effusion, 294 
of quarantine, 315 
of rectal feeding, 147 
of recurrent bronchitis, 487 

without asthma, 274 
of retropharyngeal abscess, 255- 

257 
of rheumatism m acute endocardi- 
tis, 306 

in asthma, 276 
of rickets, wet-nursing, 464 
of round-worm infection, 227 
of septic infection of the navel, 50 
of severe intestinal infection, 209 
of tardy malnutrition, 165 
of thyroid extract in cretinism, 

468 



INDEX 



599 



Cases illustrative of traumaticl aryn- 
gitis from the inhalation of car- 
bolic acid, 266 
of ulceration of the stomach, 195 
of unexplained temperature, 502 
of use of antitoxin before diagno- 
sis, 317 
in intubation cases, 319 
of lavage in vomiting, 193 
Castor oil, 208 

administration of, 525 

in bronchitis, 273 

in constipation, 185 

in convulsions, 381 

in icterus neonatorum, 50 

in ileocolitis, 213, 218 

in influenza, 474 

in intestinal indigestion, 172 

infection, 208 
in laryngitis, 261 
in round-worms, 226, 227 
in summer complaint, 200 
in tapeworm, 228 
in tetany, 383 
in urticaria, 430 
in worms, 226-228 
initial dose in acute gastro-intes- 
tinal infection, 203 
Catarrh, nasal, due to adenoids, 246 
to hay-fever, 246 
to hypertrophied turbinates, 246 
to Klebs-Loffler bacillus, 246 
to malnutrition, 246 
treatment of, 247 
Catarrhal pneumonia. See Pneumo- 
nia, broncho-. 
Catheterization of larynx in asphyxia 
of the newly born, 49 
of urethra in retention of urine, 351 
Catheters, soft-rubber, as stomach- 
tubes, 141 
Cauliflower, when allowed, 137 
Cauterization of hypertrophied tonsils, 
252 
of nasal septum in nasal hemorrhage, 
246 
Cavities in first teeth, 35 
Cephalhematoma, 50 
suppuration in, 50 
treatment of, 50 
Cereal gruels, 125 

beginning feeding of, 125 
in acute illness, 126, 140 

intestinal infection, 208 
in condensed milk feeding, 118 
in cow's milk, idiosyncrasies, 114 
in difficult cases, 113 
in feeding dispensary patients, 104 
in milk adaptation, 108 
not good for an exclusive diet, 1 26 
percentages of, 130 
to replace milk, 126 
variety in kind of, value, 203 



Cereals, high proteid, 151 

in nephritis, 358 

ready to serve, 151 

when allowed, 134 

with butter and sugar, 185 
Cerebellar ataxia, hereditary, 557 
Cerebral palsy associated with idiocy, 

405 
varieties of, prenatal, birth, post- 
natal, 403 
Cerebrospinal meningitis, 392 
deafness from, 444 
serum treatment, 392 
vaccine therapy in, 531 
Cereo for dextrinizing cereal gruels, 
129 
in typhoid fever, 479 
Cerium oxalate in gastric indigestion, 

189 
Certified milk, 199 

requirements of the New York 
County Medical Society Milk 
Commission for the production 
of, 89 
Cervical adenitis due to adenoids, 446 
to decayed teeth, 446 
to large tonsils, 446 
in scarlet fever, 333 
in typhoid fever, 478 
caries, tubercular, 258 
Chair suitable for children, 539 
Changes in temperature, sudden, dan- 
gerous in nephritis, 522 
Chapin dipper, 95, 182 
Cheese-cloth for diapers in typhoid 

fever, 479 
Cherries, when allowed, 137 
Chicken broth, formula for preparing, 

1 29. 
Chicken-pox, 346. See also Varicella. 
Child nagging, 60 

Chill in onset of pneumonia, lobar, 
286 
in pyelitis, 368 
Chilling skin a cause of suppression of 

urine, 351 
Chloral hydrate, 196 
in convulsions, 381 
in laryngismus, 265 
in meningitis, 391, 392 
in tetanus neonatorum, 56 
in uremic convulsions, 360 
Chlorate of potash, effect on kidneys, 

in stomatitis, 234 

in tonsillitis, 251 
Chlorid of iron, administration, 526 
Chloroform as an anesthetic in children, 

517 
as a counterirritant, 515 
contraindications for, 517 
danger-signals in use of, 517 
in asthma of older children, 279 



6oo 



INDEX 



Chloroform in convulsions, 381 

liniment in acute articular rheuma- 
tism, 516 

sudden death from, 471 
Chlorosis, 460 

country living in, 462 

treatment of, 462 
Cholelithiasis causing jaundice, 459 
Cholera infantum, 202 
Chorea, 384-387 

antirheumatic diet in, 385 

arsenic in, 386 

aspirin in, 386 

associated with cardiac disease, 310 

bicarbonate in, 385 

candy in, 385 

Fowler's solution in, 386 

intermittent medication in, 386 

meat eating in, 385 

play in, 385 

rest treatment in, 384 

rheumatism in, 384, 385 

salicylates in, 385 

school in, 385 

shot-bag exercises for, 542 

sugar in, 385 
Choreiform movements due to intes- 
tinal toxemia, 173 
Chrysarobin in ringworm of the scalp, 

437 
Circumcision, 371 

after balanitis, 371 

death of a bleeder after, 473 

for masturbation, 456 

for paraphimosis, 371 

for phimosis, 370 

for relief of painful micturition, 350 
Citrate of iron. See Iron. 

of magnesia. See Magnesia. 

of potash. See Potassium. 
Clean milk, cost of producing, 88 
Cleft-palate, 418 

feeding in, 419 

operation for, 418 
Climate, change of, to cure grippe, 
476 

in asthma, 276, 522 

in bronchiectasis, 301 

in care of delicate children, 149 

in cure of poor appetite, 132 

in intestinal diseases, 197, 215 

in nephritis, 363 

in pulmonary diseases, 523 

in tuberculosis, 299, 523 

therapeutic value of, 522 
Clitoris, adhesions of, a cause of incon- 
tinence of urine, 352 
of masturbation, 456 
deterrent to growth, 149 
Clothing, 538 

average weight of, 32 

for delicate children, 153 

for summer months, 509 



Clothing for use in gymnastic thera- 
peutics, 535 
in acute illness, 166 
in anemia, 461 
in bronchopneumonia, 281 
in lobar pneumonia, 288 
too heavy in sickness, 19 
Coal-tar products in typhoid fever, 481 
Coast towns in summer, 522 
Cocain anesthesia for thoracotomy, 295 
in earache, 440 
in fissure of anus, 226 
in pertussis, 339 
Cocoa in malted milk, 183 
Coddled egg in ileocolitis, 217 
Codein in asthma, 279 
in cough of measles, 346 

of pleurisy, 292 
in diphtheritic paralysis, 400 
in endocarditis, 305 
in meningitis, 391 
in multiple neuritis, 402 
in pericarditis, 303 
in pertussis, 341 
Cod-liver oil, 388 

in bronchiectasis, 302 
in cardiac disease, 312 
in condensed milk feeding, 175 
in constipation, 181 
in marasmus, 162 
in milk idiosyncrasy, 114 
in neuritis, 402 
in neurotic children, 380 
in nurslings, 179 
in persistent adenitis, 447 
in tubercular adenitis, 452 
in vulvovaginitis, 374 
Coffee after sixth year, 138 
in typhoid, 479 

insufflations of, in pertussis, 338 
Coit, H. L., organizer of the first milk 

commission, 88 
Cold air contraindicated in asthma, 

27q 

baths, uses of, 521 
chronic, due to adenoids, 449 
coil, use of, 521 

compress in adenitis, acute, 446 
cervical, 333 

in catarrhal croup, 262 

in glandular fever, 494 

in tonsillitis, 251 

use of, 521 
cream inunction in measles, 34.5 
douche in neurotic children, 379 

uses of, 522 
dry air in summer, 522 
feet and colic, 176 
foods better retained than hot, 189 

in acute illness, 167 
in delicate children, 153 
in head, 240, 241 
pack, 503 



INDEX 



60 1 



Cold pack in bronchopneumonia, 284, 
285 
in diphtheria, 324 
in endocarditis, malignant, 307 
in erysipelas, 485 
in fever, 498 
in gastro-intestinal infection of the 

choleraic type, 202 
in influenza, 574 
in lobar pneumonia, 289 
sponging in fever, 502 
in grippe, 474 
in hot weather, 503 
in pneumonia, 285 
in typhoid fever, 478, 482 
uses of, 521 
therapeutic uses of, 521 
water enema after colon flushing, 
210 
Colic causing hernia, 415 
due to decomposition, 176 

to defective bowel action, 176 
to milk proteid, 176 
to mother's constipation, 176 
to round-worms, 226 
to too much fat, 100 
to too much proteid, 100 
to too strong food, 100 
in bottle-fed, 176 
in breast-fed, 176 
in difficult feeding cases, 112 
nervous causes of, 176 
stupes in, 516 
treatment of, 176 
Coliopyelitis, 368 

Colitis as cause of fecal incontinence, 
230 
chronic, years to get results in, 18 
Collecting urine, device for, 350 
Colon bacillus in cystitis, 367 
in urine of pyelitis, 368 
flushing, 518 

apparatus for, 220 

in cyclic vomiting, 494 

in gastro-intestinal infection, 202, 

203, 204 
in ileocolitis, 217, 219 
in intestinal infection, 209 
in mucous colitis, 218 
in nephritis, 359 
in persistent vomiting cases, 189 
in pneumonia, lobar, 291 
in suppression of urine, 351 
indications for, 220 
irrigation in acute intestinal infec- 
tion, 210 
in fever, 220 
medication in laryngismus stridu- 
lus, 266 
Colostrum, 77 
Coma, gavage of peptonized milk in, 

119 
Comfort baths for hot weather, 30 



Compress, cold. See Cold compress. 
Condensed milk after diarrhea, 207 
analysis of, 118 
as cause of malnutrition, 162 

of rickets, 464 
as sick food, 1 1 8 
for summer, 161 
for traveling, 122 
in convalescence of ileocolitis, 216 
in difficult feeding cases, 112 
in out-patient work, 104 
in premature infants, 47 
Conduct of life in valvular disease of 

the heart, 310, 313 
Congenital defects causing intestinal 
obstruction, 221 
heart disease, 313 
pyloric stenosis, 196 
Congestion, internal, 516 

counterirritation for, 516 
Constipation after diarrhea, 209 
after ileocolitis, 216 
cascara in, 179 

due to fissure of the rectum, 181 
to inflammation of anus, 225 
to sterilizing milk, 115 
to too high fat, 182 
to too low fat, 73 
gymnastic exercises for, 569 
in bottle-fed, iSo 
in chronic ileocolitis, 217 
in difficult feeding cases, 112 
in mucous colitis, 218 
in nursing mothers, 70 

a cause of colic in child, 176 

of constipation in child, 178 
treatment of, for eczema in 
child, 421 
in nurslings, 178 
in older children, 181 
in peritonitis, 491 
not an index of intestinal toxemia, 

173 
treatment of, 177-186 
Contagious diseases, care to be exer- 
cised in attending, 314 
Continence of urine, when established, 

350 
Convulsions, infantile, a cause of cere- 
bral hemorrhage, 381 
of epilepsy, 381 
chloral in, 38 1 

chloroform inhalations in, 381 
diet after, 381 
due to atelectasis, 51 

to enlarged thymus, 382 

to gastro-intestinal irritation, 

380 
to phimosis, 380 
to rachitis, 380 
to worms, 226 
from birth trauma, 380 
in acute nephritis, 361 



6o2 



INDEX 



Convulsions, infantile, in dentition, 36 
in onset of acute intestinal infec- 
tion, 208 
of lobar pneumonia, 286 
in pertussis, 337 
management of, 381 
uremic, 361 
Cooling of milk, 91 
Cooperation of mother in treatment 

of the children, 19 
Cord, 26. See Umbilical cord. 

stump, cauterization of, in tetanus 
neonatorum, 56 
Corn starch, when allowed, 136 
Cornmeal gruel in the diet of the nurs- 
ing mother, 75 
Corrosive drugs as source of gastritis, 

188 
Coryza, recurrent, 245 

associated with cardiac disease, 
310 
Cough in laryngitis, 259 

chronic, due to adenoids, 448 
paroxysmal, but not pertussis, 337 
pharyngeal, 248 
Count erirritants for relief of conges- 
tion, 515 
Counterirritation in acute gastric indi- 
gestion, 189 
in bronchitis, 272 
in bronchopneumonia, 282 
in lobar pneumonia, 288 
in pleurisy, 292 
Country living in chlorosis, 469 
Cow's milk. See Milk, cow's. 
Cracked wheat, when allowed, 136 
Cream, age of, for infant feeding, 94 
Alderney, 1 1 1 
centrifugal, iii 

digestibility of, gravity and centrif- 
ugal, III 
gravity, 1 1 1 

in constipation before nursing, 179 
Jersey, iii 
mixtures, 161 
Crede's ointment in cervical adenitis of 

scarlet fever, 334, 446 
Creolin baths in pemphigus, 431 
Creosote, administration of, 526 
in chronic bronchitis, 274 
in pertussis, 339 
in steam inhalations, 271 
Cretinism, 405, 467 
Crisis in lobar pneumonia, 287 
Croup, catarrhal. See Laryngitis, acute 
catarrhal. 
diphtheritic. See Diphtheria, laryn- 
geal. 
in bronchitis, 271 
kettle, 261 
spasmodic, 259 
Crying, habitual, due to discomfort, 27 
necessary at birth, 51 



Crying, use of, 26 
varieties of, 27 
Curds in stools due to too high proteid, 

73 
of breast-fed, 73 
Custard, frozen, in illness, 140 

when allowed, 136 
Cyanosis due to atelectasis, 51 
Cyclic vomiting, diet in, 494 
drugs in, 495 

due partly to rheumatic taint, 495 
Cystitis, 367 

as cause of incontinence of urine, 352 
rare in boys, 367 



DactyIvITis, syphilitic, 492 
tuberculous, 492 

Danger-signals in ether, gas, and chlo- 
roform, 517 

Dark room in measles, 344 

Day terrors, 173 

Deaf children often regarded as stupid, 

444 
Deafness, acquired, 444 
due rarely to mumps, 444 

to adenoids, 444 

to cerebrospinal meningitis, 444 

to enlarged tonsils, 444 

to Eustachian disease, 444 

to middle-ear disease, 444 

to syphilis, 444 
following scarlet fever, 334 
temporary, in diphtheria, grippe, 

tonsillitis, and the exanthemata, 

444 
transitory, in pertussis, 337 
Death from acute gastro-intestinal 
infection, 202 
from atelectasis in the newly born, 60 
from persistent hematemesis from 
ulcer of the stomach, 196 
Death-rate due to measles, 344 
to pertussis, 336 
to syphilis, 444 
Decubitus, sites of, 435 
Delicate child, care of, 149-156 
definition of, 148 
examination of, 149 
parents beget delicate children, 149 
Delphinium, 436 

Delusions, optical, in intestinal tox- 
emia, 174 
Deming milk modifier, loi, 102 
Denhard gag, 143, 450 
Dentition as cause of convulsions, 36 
of digestive disturbances, 36 
diet during, 36 
disturbances of, 36 
feeding during, 36 
in respiratory diseases, 36 
in skin diseases, 36 
in well children, 36 



INDEX 



603 



Dentition, late, 36 

multiple, 36 
Depressed nipples, 79 
Dermatitis gangrenosa a sequel of 

chicken-pox, 347 
Detail in the treatment of children, 17 
Development at the Babies' Hospital 
Dispensary, 58 
percentage of normal development 
in the New York Polyclinic Out- 
patient Department, 58 
Dew method of artificial respiration, 

Dextrinized barley-water, formula for 

making, 129 
gruels after diarrhea, 207 

after ileocolitis, 216, 217 
Diabetes insipidus, 366 
mellitus, 366 

diet in, 367 

drugs in, 366 

fatality in, 366 

loss of weight in, 366 

thirst in, 366 

urine in, 366 
Diacetic acid, absence of, in glycosuria, 

365 
Diachylon plaster in the treatment of 

decubitus, 436 
Diagnostic methods, vaccine, 532 
Diaper washer, 20 
Diapers, 20 

care of, 20 

protector for, 20 
Diarrhea a conservative process, 204 

due to too high fat, 72, 177 

in typhoid fever, 480 

initial treatment of, in breast-fed, 
172 

onset of, 171 

stopping milk in, 172 
Diarrheal diseases, etiologic factors in, 

198 
Diet after adenoid operation, 451 

after the sixth year, 138 

antidiabetic, 367 

antirheumatic, in chorea, 385 

during dentition, 36 
illness, 139 
second year, 58 

often too low in proteid, 134 

high proteid, in delicate children, 

in acute illness, 167 

in adenitis, tubercular, 452 

in anemia, 461 

in bronchitis, 271 

recurrent, 275 
in bronchopneumonia, 281 
in cardiac disease, 311 
in constipation, 182 
in convulsions, 381 
in diabetes, 367 



Diet in diphtheria, 323 
in endocarditis, acute, 305 
in epilepsy, 389 
in erythema nodosum, 432 
in incontinence of feces, 231 
in influenza, 474 
in intestinal indigestion, 174 
in jaundice, obstructive, 459 
in laryngismus stridulus, 266 
in lobar pneumonia, 289 
in measles, 345 
in meningitis, 391 
in mucous colitis, 219 
in nephritis, 362 
in night-terrors, 382 
in rheumatism, 486, 488 
in rickets, 465 
in scarlatina, 329 
in tardy malnutrition, 165 
in tuberculosis, pulmonary, 299 
non-constipating, after second year, 

183 
for five to ten years, 184 
schedule, for feeding, after the first 
year, 134-140 
Dietetic errors, a predisposing cause to 

rheumatism and endocarditis, 486 
Difficult feeding cases due to cow's 

milk intolerance, 112 
Digestion of starch, 126, 127 

disorders of, due to dentition, 36 
Digestive power best in morning, 165 
Digitalin in acute intestinal infection, 

210 
Digitalis, abuse of, 313 
administration, 526 
as a heart stimulant for young chil- 
dren, 290 
in bronchopneumonia, 284 
in cardiac disease, 310, 312 
in diphtheritic paralysis, 401 
in ileocolitis, 214 
in myocarditis, 307 
in nephritis, 357 
in scarlet fever, 332 
use may be attended with harm, 19 
Dilatation of stomach, 194 
causing vomiting, 186 
in chronic gastritis, 190 
in marasmus, 160 
Diluted food in bronchitis, 271 
in bronchopneumonia, 281 
in illness, 139 
in scarlet fever, 329 
in tonsillitis, 250 
Dilution of drugs, 526 
Dining alone, 138 
Diphtheria, antitoxin rash in, 321 
and myocarditis, 307 
cause of, 316 

acute endocarditis, 321 
cervical adenitis in, 316 
cool pack in, 316 



6o4 



INDEX 



Diphtheria, effect of antitoxin on mem- 
brane in, 318 
on temperature in, 318 
foul breath in, 316 
gargle in, 323 
gavage in, 316 
general treatment in, 323 
inhalations in, 323 
Klebs-Loffler bacillus in, 316 
laryngeal, 318 

antitoxin dosage in, 318 
intubation in, 326-328 
onset of, 318 
late giving of antitoxin in, 320 
leukocytes in, 321 
location of membrane in, 316 
nasal, 242 

rectal feeding in, 314 
sponge bath in, 314 
spray in, 323 
strophanthus in, 314 
strychnin in, 324 
throat irrigation in, 258, 323 
transmission by kissing, 28 
vaporization in, 323 
versus streptococcus throat, 318 
Diphtheritic paralysis, percentage of 
occurrence of, 399 
peptonized milk by gavage in, 119 
Diplegia, 404 
Diplococcus intracellularis, effects of 

Flexner's serum on, 393, 394 
Directions for the care of the child, 39 
Disinfection of the excreta in typhoid 

fever, 478 
Disorders of speech due to intestinal 

toxemia, 173 
Dispensary patients, feeding of, 102 
written instructions for the feed- 
ing of, 200 
Diuretics in nephritis, 360 
Double mirror for gymnastic exercises, 

535 
room for sickness, 476 
Douche bag for ear irrigation, 443 

cold, 29 
Dover's powder, 346 

in bronchitis, 231 

in cough of bronchopneumonia, 
283 

in diarrhea, 205 

in fever, 499 

in ileocolitis, 213 

in laryngitis, 261 

in rhinitis, 243 

in typhoid fever, 481 

with bismuth in fecal incontinence, 
231 
Drafts, 37 

Drainage of summer home, 514 
Drinking water in acute illness, 167 

in measles, 345 

with meals, 195 



Drop method for ether anesthesia, 517 
Drugs and drug dosage, 575-591 
nauseating and unpalatable, 524 

those which may harm, 19 
use of, in acute illness, 169 
in cardiac disease, 310 
in endocarditis, 305 
in gastro-intestinal indigestion, 

189 
in meningitis, 391 
promiscuous, by family, 523 
Dry supper in treatment of inconti- 
nence of urine, 354 
Duodenitis causing obstructive jaun- 
dice, 459 
Duration of tub-baths, 29 
Dust, importance of, in measles-pneu- 
monia, 344 
Dusting-powder, 26 
in furunculosis, 434 
in gonorrheal vaginitis, 375 
in granuloma, 53 
in intertrigo, 424 
in prickly heat, 439 
in vulvovaginitis, 374 
Dysarthria due to intestinal toxemia, 

174 
Dysphagia in retropharyngeal abscess, 

355 
in tonsillitis, 250 



Ear, examination, 442 

pulling, 454 

syringes, 443 
Earache, camphor water in, 440 

measures to relieve, 440 
Eating, bad, 59 

between meals causing loss of appe- 
tite, 132 

utensils, care of, in the sick-room, 

315 
Eczema about a suppurating navel, 

26 
as cause of malnutrition, 421 
associated with acid urine, 421 

with high fat, 422 
sugar, 422 

with recurrent bronchitis, 421 
due to faulty metabolism, 421 

to maternal nursing, 421 

to salivation, 232 

to soaps, 423 

to woolens, 423 
fresh cow's milk in, 422 
intertrigo, 424 
mask in, 423, 427 
neurotic, 425 
of older children, 425 
seborrheic, 427 
straight-jacket in, 423, 429 
treatment of, external, 422, 423 
washing face in, 423 



INDEX 



605 



Edema of larynx, intubation in, 324 
Education of mother about feeding, 

200 
Eggs excluded in the diet of neph- 
ritics, 362 

in delicate children, 151 

soft-boiled, when allowed, 135 
Egg-water, formula for making, 129 
Electricity in Erb's paralysis, 406 

in facial paralysis, 403 

in multiple neuritis, 402 

in poliomyelitis, 399 
Electrotherm in premature infants, 

45, 46 
uses of, 521 
Elixir simplex as a vehicle, 526 
Emphysema due to asthma, 277 
Empty stomach, giving drugs on, 526 
Empyema, development of, 294 
double, 297 

encysted, a cause of obscure eleva- 
tion of temperature, 501 
exploration of chest in, 295 
insufficient drainage in, 296 
irrigation of the cavity, 403 
mistaken for tuberculosis, 294, 295 
for typhoid, 295 
for unresolved pneumonia, 295 
necessitatis, 298 
pocketing of pus in, 296 
removal of tube after thoracotomy 

for, 297 
resection of a rib for, 296 
thoracotomy for, 295 
vaccine therapy in, 530, 531 
Endermic feeding, 144 
Endocarditis a part of rheumatism, 

485 
diet m, 305 
heart action in, 306 
ice-cap for, 305 
in diphtheria, 304 
in influenza, 304, 475 
in rheumatism, 304 
in scarlet fever, 304 
malignant, with diphtheria, 307 

with scarlet fever, 307 

with tonsillitis, 307 
rheumatic, recurrence, 310 
salicylates for, 306 
septic, 307 
Enema after ileocolitis, 216 
in colic, 176 
in constipation, 177, 181 

of nursing mothers, 70 
in convulsions, 381 
in ileocolitis, 217 
in pneumonia, lobar, 288 
in typhoid fever, 480 
initial treatment of all cases of 

vomiting, 188 
nutrient, 147 
soapsuds, 177, 330 



Enema, soapsuds, in retention of urine, 

351 
standing order for, 177 
Energy expended by a child, 28 
Enterocolitis a cause of peritonitis, 
491 
alcohol in, 520 
Enuresis, 352. See also Incontinence 

of urine. 
Environment, 453 

a factor in artificial feeding, 82 
in growth of child, 57 
in intestinal diseases, 197 
in marasmus, 159 
unfavorable, 197 
Epilepsy a contraindication to mater- 
nal nursing, 76 
bowel function in, 389 
bromids in, 389 
diet in, 389 

due to infantile convulsions, 381 
fatigue in, 389 
institutions for, 389 
intestinal toxemia in, 389 
irritative lesions in, 389 
management of, 388-390 
Epiphyses, enlarged, 463 

separation of, in scurvy, 467 
Epispadias, 369 

Epistaxis, 246. See also Nasal hemor- 
rhage. 
Epitrochlear glands, enlarged, in syph- 
ilis, 410 
Epsom salts in enema, 210 
Erb's paralysis, 406 
Ergot in poliomyelitis, 398 

in purpura, 472 
Ermold, George, lamp for calomel 

fumigations, 263 
Errors in feeding, 133 
Erysipelas, 483-485 
applications for, 484 
drugs for, 484 
feeding in, 484 
following vaccination, 507 

, varicella, 347 
hygiene in, 484 
in the newly born, 49 
mortality of, 483 
scarifications for, 483 
vaccine therapy in, 530 
Erythema multiforme, 433 
nodosum, 432 
diet in, 432 
duration of, 433 
in peliosis rheumatica, 432, 491 
lead and opium for, 432 
potassium iodid for, 432 
rheumatic nature of, 432 
Ether anesthesia by preference in 
adenoids, 450 
contraindications for, 517 
danger signs of, 517 



6o6 



INDKX 



Ether anesthesia in children, 516 
Ethyl chlorid, 517 

Eustachian tube, catarrh of, as cause 
of persistent deafness, 444 
due to adenoids, 252 
to tonsils, 252 
infected by nasal syringing, 243 
Evaporated cream, 118 
Every-day care of feeding, 58 
Ewing, James, quoted, 321 
Examination before gymnastic thera- 
peutics, 317 
monthly, 32 
of delicate child, 149 
of ear drum, 440 
of patient, first, 39 
of throat, 249 
Exercise as cause of elevation of tem- 
perature in nervous children, 499 
baskets, 25 
conditions under which to be taken, 

534 
effect on the milk of nursing mother, 

75 

for correcting postures, 541 

for delicate child, 155 

for nursing mother, 71 

in cardiac disease, 311 

in cure of obesity, 460 

in nephritis, 363 

pen, 26, 37, 154, 241 
Expectorant treatment in catarrhal 

croup, 260 
Expectorants in bronchopneumonia, 

283 
Exploration of chest, 295 
Expression of milk during suspended 

nursing, 172 
External auditory meatus in mas- 
toiditis, 445 
Extractum ferri pomatum, 462. See 

also Iron. 
Extravasation of blood in pertussis, 

338 
Exudate, pleural, 292 
Eyes, care of, in measles, 345 
Eyestrain, headache often the only 

sign of, 376 



Face mask in eczema, 423, 427 
Facial paralysis due to otitis, 402, 403 
Farina gruel as a cereal, when allowed, 
136 
when allowed, 136 
Fat an essential ingredient of food, 61 
as cause of malnutrition, 162 
badly borne in ileocolitis, 217 
diarrhea due to, 106 
excess of, in food, signs of, 106 
function of, 62 

high, occasional cause of constipa- 
tion, 180 



Fat, high, in proprietary foods, 1 23 
indigestion, 106 

a factor in the constipation of 

bottle-fed babies, 180 
signs of, 106 
inunctions, 144 
limit of, for older children, 182 
low, an occasional cause of consti- 
pation, 178 
where found, 62 
Fatigue a cause of fever, 500 
of headache, 376 
in chorea, 384 
in epilepsy, 389 
Faucitis, 247 

treatment of, 248 
Fecal impaction causing intestinal 
obstruction, 222 
masses a cause of fissure, 225 
Feces, incontinence of, 230 

starch converting enzyme in, 126 
Feeding after diarrhea, 205 
first year, 134-140 
ileocolitis, 23 
vomiting, 204 
artificial, 82 
buttermilk, 120 

defective, a cause of tardy malnu- 
trition, 165 
fermented milk, 120 
forced, in tuberculosis of children, 

299- 493 
frequency of, in chronic ileocolitis, 

217 
in acute gastro-indigestion, 189 
in delicate children, 150, 151 
in erysipelas, 484 
in gastritis, chronic, 190 
in illness, art of, 140 
in malnutrition of infants, 163 
in marasmus, 160-162 
in premature infants, 47 
in sepsis, 49 
in sprue, 236 
in stomatitis, 234 
in tonsillitis, 250 
in typhoid fever, 479, 480 
malt-soup, 109, 112 
methods, faulty, a cause of diarrheal 
diseases, 198 

instructions in, for poor, 200 
of full milk, 103 
sour milk, 120 
substitute, Chapin dipper for, 96 

condensed milk and, 103 

diluting milk in, 93 

for dispensary patients, 102 

full milk, 103 

home modification in, 104 

intervals in colicky babies, 176 

laboratory feeding, 100 

milk adaptation in, 106-111 

modifying milk, 92 



INDEX 



607 



Feeding, substitute, number of feed- 
ings, 96-99 
whey and cream mixtures in, 97 
through skin, 144 

too frequent, a cause of loss of appe- 
tite, 131 
Fermented milk, 1 20 
Fetor of breath in noma, 236 
Fever, hydrotherapy in, 498 
in acute illnesses, 497 
in chronic discharging ear case, a 

sign of mastoiditis, 445 
in otitis, 441 
persistent, due to intestinal toxemia, 

173 
Finger sucking, 454 
Fireplace as ventilator, 43 
Fish, when allowed, 137 
Fissures at angle of mouth, 238 
of anus, 225 
of lips, 238 

of rectum a cause of constipation, 
181 
Flat chest, causes of, 540 
exercises for, 546, 547 
rare in infants, 540 
Flat-foot, examination for, 573 
exercises for, 574 
massage for, 574 
shoes for, 575 
Flexner's serum for cerebrospinal men- 
ingitis, 392 
effects of, 393, 394 
method of use, 395 
Floor, playing on, 153 

sitting on, a cause of colds, 240 
Florida for nephritis cases, 522 
Fluid in the chest, 293 
Food, adaptation of, 62 

assimilation key to infant feeding, 

58, 62 
decomposed, a cause of gastric indi- 
gestion, 188 
for premature babies, 47 
forcing, 134 
fried, 138 
infected, a cause of summer diarrhea, 

197 
properties and ingredients, 61 
proprietary, a cause of rickets, 464 

containing alcohol, 380 
quantity of, at a feeding, 133 
temperature of, in stomatitis, 235 
too concentrated, a cause of consti- 
pation, 182 
too strong, signs of, 100, 106 
too weak, signs of, loq, 106 
unsuitable, a cause of acute gastric 

indigestion, 188 
utensils, care of, in congenital syphi- 
lis, 409 
in quarantine, 315 
Forceps, laryngeal, 267 



Foreign bodies in larynx, removal of, 
267 
in nose a cause of nasal catarrh, 

Foreskin, incision of, in paraphimosis, 

370. See also Circumcision. 
Formalin in sprue, 236 
Formulae for condensed milk mixtures, 
104 
for feeding dispensary patients, 103, 
104 
well babies, cream and milk mix- 
tures, 95, 96 
for making barley jelly, 129 
barley-water, 129 
beef-broth, beef-juice, chicken- 
broth, 129 
dextrinized barley-water, 129 
egg albumin water, 1 29 
imperial granum water, 130 
junket, 130 
mutton broth, 129 
oatmeal water, 130 
wheat jelly, 129 
whey, 130 
for top-milk mixtures, 98 
for whole milk mixtures, 103 
Foul breath in diphtheria, 316 
in noma, 336 

in ulcerative stomatitis, 233 
Fowler's solution in chorea, 386 

susceptibility to, 387 
Freeman's pasteurizer, 115, 117 
Fresh air difficult to secure, 59 
for nursing mother, 71 
in anemia, 461 
in bronchitis, 271 
in bronchopneumonia, 281 
in delicate children, 152 
in erysipelas, 484 
in growth of child, 59 
in lobar pneumonia, 288 
in marasmus, 159 
in pertussis, 342 
in premature infants, 45 
in tuberculosis, 300 
cow's milk in eczema, 422 
in scurvy, 467 
Friedreich's ataxia, exercises for, 549 
Fright causing vomiting, 187 
Fruit during lactation, 70 

when allowed in diet, 135, 136, 137 
Fumigation after grippe, 476 
Furnishings of sick-room, 43 
Furniture for children, 539 
Furunculosis, 434 
after varicella, 347 
treatment of, 434, 435 
vaccine therapy in, 530 

Gain in weight, amount of, in success- 
ful maternal nursing, 72 
normal, under one year, 150 



6o8 



INDEX 



Galvanocautery in cure of hyper- 
trophy of tonsils, 252 
Gargles in diphtheria, 323 
Garlic, infusion of, in thread-worms, 

227 
Gas-ether anesthesia, 517 
Gastritis, acute, beginning grippe, 475 
causes of, 187 
treatment of, 188 
chronic, 190 

barley-water in, 190 
cause of, 190 
following acute, 189 
treatment of, 190 
Gastro-enteritis as cause of suppres- 
sion, 351 
cereals to replace milk in, 126 
complicating erysipelas, 484 

pertussis, 337 
onset of, 204 
symptoms of, 202 
termination of, 204 
treatment of, 202 
Gastro-enterostomy in congenital py- 
loric stenosis, 197 
Gastro-intestinal intoxication, 202 
irritation as cause of convulsions, 
380 
Gavage, 140-144 
amount of, 143 
frequency of, 143 
in cleft -palate, 419 
in diphtheria, 324 
in hare-lip, 418 
in lobar pneumonia, 291 
in marasmus, 158, 159 
in meningitis, 391 
in persistent vomiting, 189 
in post-diphtheritic paralysis, 400, 

401 
in sepsis, 49 

in tetanus neonatorum, 56 
Genitals, female, 374 

uncleanliness of, in difficult urina- 
tion, 350 
male, 369 
Geographical tongue, 239 
Giant hives, 407 
Gin in colic, 177 
Ginger-ale, 140 

Gingivitis in typhoid fever, 478 
Girls, hysteria in, 377 

masturbation in, 455 
Glands of neck in diphtheria, 316 
in tonsillitis, 249 
retropharyngeal, suppuration of, 254 
See also Adenitis, cervical. 
Glandular fever, 493 
Glass tube for taking iron, 526 
Glasses for relief of headache, 376 
Glauber's salt in gastro-intestinal infec- 
tion, 203 
Glycerin suppository, 177 



Glycerin suppository adjuvant in oil 

treatment of constipation, 185 
Glycosuria, diabetic, 366 

dietetic, 365 

temporary, 365 
Gonococcus infection, vaccine therapy 

in, 531 
Gonorrhea in female, 374 

bacteriologic examination before 
discharge of case of vaginitis, 

375 
method of infection of, 374 
treatment of, 375 
in male, 372 
in nursery maids, 23 
Good food most important factor in 

nutrition, 57, 58 
Goose-oil rub, 145, 152, 164 
in habit spasm, 388 
in tetany, 384 
in tuberculosis, 300 
Granuloma, 26, 53 
Granum-water, 190 

after gastro-intestinal infection, 203 
formula for, 130 
Gravity cream, 1 1 1 
Green vegetables in diet of child, 151 

in rheumatism, 486 
Grindelia robusta in ivy-poisoning, 433 
Grippe, 474. See also Influenza. 
Ground-floor, child to sleep above, 

514 
Growing pains a part of rheumatism, 

485 
Growth of child as regards his future, 

57 
Gruels. See Cereal gruels. 
Gums, bleeding, in ulcerative stomati- 
tis, 475 
Gymnastic therapeutics, 534-574 

adaptation to practical ends in, 

536 
anterior poliomyelitis treated by, 

571 
breathing in, 542 

congenital ataxias treated by, 556 
constipation treated by, 569 
duration and frequency of treat- 
ments in, 534-537 
exercises for correcting bad pos- 
tures, 541 
flat chest, exercises for, 546, 547 
for Friedreich's ataxia, 557 
for hereditary cerebellar ataxia, 

557 
flat-foot treated by, 573 
general considerations in, 538 
kyphosis treated by, 547-551 
period of treatment in, 535 
posture and breathing in, 537 
scoliosis treated by, 551 
Gyrospasm, 382 
in idiots, 383 



INDEX 



609 



Habit cough, 268 
spasm, 387 
diet in, 387 
drugs in, 388 
related to chorea, 388 
to rheumatism, 388 
Habits of bowel evacuation, 177 
of ear pulling, 455 
of masturbation, 454 
of self-entertainment, 454 
of sleep, 454 
of thumb-sucking, 454 
to be discouraged, 454 
to be encouraged, 454 
Hands, care of, after diapering, 20 
Hare-lip, 418 
feeding in, 418 
operation for, 418 
Hay-fever a cause of nasal catarrh, 

244, 276 
Head covering a cause of colds, 240 
nodding, 382 
position of, in retropharyngeal 

abscess, 255 
rest for preventing decubitus, 436 
Headache a possible sign of meningitis, 
376 
due to eye-strain, 376 

to intestinal indigestion, 376 
to nitroglycerin, 290 
habitual, an evidence of intestinal 

toxemia, 173 
in malaria, 376 
in nephritis, 376 
in onset of acute infections, 376 
in pneumonia, 376 
in scarlet fever, 376 
Hearing, acuteness of, in early months, 

444 
age established, 444 
Heart, action of, in acute endocarditis, 
306 
in myocarditis, 308 
in post-diphtheritic paralysis, 400 
disease, congenital, 313 
length of life in, 313 
manner of death in, 313 
treatment of, 313 
valvular, 310-313 

associated with chorea, 310 
with recurrent bronchitis, 310 
with tonsillitis, 310 
conduct of life in, 310, 311 
diet in, 310 
digitalis, 312 
exercise in, 310 
origin of, in rheumatism, 310 
prognosis in, 311 
sugar eating in, 310 
treatment of, 310-313 
failure in diphtheria, 320 
rest, 307, 309, 312 
stimulants, 313 

39 



Heart stimulants, abuse of, 313 

in pneumonia, 284, 289 

indications for, 313 
Heat, dry, in nephritis, 360 

in pain of neuritis, 402 

therapeutic applications of, 520, 
521 
Height, significance of, 34 

table of, 33 
Hematemesis due to Henoch's purpura, 

194 
to swallowing blood, 194 
to ulcers, 194, 195 
in cyclic vomiting, 494 
of newly born, 194 
persistent, an evidence of ulcer of 
stomach, 196 
treatment of, 196 
Hematoma of sternomastoid, 418 
Hemiplegia, 404 
Hemophilia, 472 

calcium lactate in, 473 

hereditary transmission in, 453 

in hemorrhagic diseases of the newly 

born, 54 
treatment of, 472 
Hemorrhage, cerebral, due to convul- 
sions, 381 
from stomach, 194. See also Hema- 
temesis. 
meningeal, causing cerebral palsy, 

403 
Hemorrhagic diseases in the newly 
born, 53 
treatment of, 54 
Hemorrhoids rare in children, 230 
Hereditary cerebellar ataxia, 557 
Heredity and environment, 553 
as factor in posture, 540 
in growth of a child, 57 
in hemophilia, 472 
in hysteria, 377 
Hernia, inguinal, 415 
causes, 415 
occurrence, 415 
operation for, 415 
trusses for, 415 
strangulated, causing intestinal ob- 
struction, 222 
umbilical, 416 

treatment of, 416 
ventral, 417 

treatment of, 417 
Herniotomy, 415 
Herty mask, 427 

Hiccough due to distention of stom- 
ach, 407 
High fat after diarrhea, 206 

mixtures in constipation, 182 
proteid diet for child in school, 59 
in malnutrition, 163 
Hirt, quoted, 385 
History, family, importance of, 40 



6io 



INDKX 



History record, 40 

taking, 40 
Hives, 429. See also Urticaria. 
Hoarseness in congenital syphilis, 410 
Holt's croup-kettle, 261 

milk-set, 65 
Hominy, when allowed, 136 
Honey and borax for sprue, 236 
Hot air, use of, 521 

and cold baths in asphyxia of newly 

born, 48 
bath for acute gastro-intestinal infec- 
tion, 202 
in nephritis, 360 
in tetany, 350 

to bring out measles-rash, 345 
uses of, 520, 521 
fomentations in mumps, 348 
irrigation of throat, 254 

use of, 520, 521 
packs in nephritis, 360 

uses of, 520, 521 
poultices, use of, 520, 521 
stupes in colic, 176, 
in ileocolitis, 214 
in retention, 351 
use of, 520, 521 
Hot-water bag in acute gastro-intes- 
tinal infection, 202 
in earache, 440 
use of, 520, 521 
Hot-water douche in earache, 440 
Human milk, percentage composi- 
tion of, 72. See also Milk, human. 
Hutchinson's teeth, 411 
Hydrocele, 372 

Hydrocephalus, chronic internal, 397 
Hydrochloric acid, 133, 195, 459, 480 
Hydrogen peroxid, 230, 234, 245, 371 
Hydronephrosis as cause of intestinal 

obstruction, 222 
Hydrotherapy in fever, 498 

in typhoid fever, 482 
Hyperpyrexia in ulcerative stomatitis, 

233 
Hypnotics, duration of administration, 

to children, 402 
Hypodermic feeding, 144 

stimulation, 291 
Hypodermoclysis, 205 
Hypophosphites, syrup of, 175, 301, 

452 
Hypospadias, 369 
Hysteria, attacks of, 379 

environment in, 377 

heredity in, 377 

treatment of, 378 



Ice-bag in adenitis, 446 
in appendicitis, 223 
in convulsions, 381 
in endocarditis, 305 



Ice-bag in glandular fever, 494 

in headaches due to fever, 376 

in mastitis, 52, 80 

in nasal hemorrhage, 246 

in pericarditis, 304 

in poliomyelitis, 399 

in quinsy, 254 

in typhoid fever, 483 

uses of, 521 
Ice-cream in illness, 140 

when first allowed, 137 
Ice-stations, municipal, 199 
Ichthyol in albolene for chronic rhini- 

in olive-oil as an inunction for 

chicken-pox, 347 
ointment in adenitis, 347, 446 

in contagious impetigo, 431 

in eczema, 423 

in erysipelas, 49, 484 

in fissure of anus, 226 
of lips, 238 
of mouth, 238 

in furunculosis, 434 

in German measles, 347 

in hemorrhoids, 230 

in inflammation of anus, 225 

in mastitis of newly born, 52 

in ulcers of nasal septum, 246 
Icterus, 459 

neonatorum, 50 
Idiocy, 404 

after convulsions, 380 
with gyrospasm, 383 
Ignorance an important factor in poor 

feeding, 59 
Ileocolitis, acute, bacteriology of, 212 

blood in stools of, 212 

colon flushing in, 214 

constipation after, 216 

diet in, 212 

drugs in, 213 

duration of, 212 

during convalescence, 215 

feeding during attack, 212 

following acute gastro-intestinal 
infection, 204, 212 

pathologic findings in, 211 

prostration in, 212 

starch injections in, 215 

stools in, 212 

temperature in, 212 

tenesmus in, 212 

treatment of, 212-216 
chronic, 216 

causing malnutrition, 216 

following acute, 216 

starch intolerance in, 217 

treatment of, 217 
Illness, acute, attendants, 166 

bowel feeding, 169 
function, 169 

clothing, 166 



INDEX 



6ii 



Illness, acute, cold air, 167 

contraindicating maternal nursing, 
76 
essentials in care of, 166 

diet, 167 

drinking of water, 167 

drugs in, 169 

keeping in bed, 166 

needless interference, 168 

pyrexia, 169 

room temperature, 167 

sick room, 167 

sponging, 167 

stimulation, 170 

suppression of urine, 169 

urine examination, 168 

ventilation, 167 
Imitation of parents mistaken for 

heredity, 377 
strong, in child, 377 
Immunity, duration of, insured by 

diphtheria antitoxin, 322 
Imperial granum-water, 125 

formula for making, 130 
Impetigo contagiosa, 431 
Inadequate diet of second year, 58 
Inanition and death-rate, 82 

fever complicating sepsis of newly 

born, 49 
Incisor teeth, time of appearing, 35 
Incontinence of feces, 230 
of urine, causes of, 352 

in cystitis, 367 

treatment of, 352, 353 

when abnormal, 350 
Incubators, baby, defective air-supply 

^^' 45 . . 
Indicanuria in persistent headache, 376 
not always present in intestinal indi- 
gestion, 173 
Indigestion, acute intestinal, 171, 172 
onset of, 171 
resuming milk in, 172 
stopping milk in, 172 
treatment of, 172 
as cause of anemia, 460 
of night-terrors, 382 
of urticaria, 430 
associated with angioneurotic edema, 
408 
with pharyngitis, 248 
gastric, acute, 188 
causes of, 188 
treatment of, 188 
intestinal, predisposing to diarrhea 

in summer, 171 
predisposing to acute intestinal 
infection, 208 
Individual, treatment of, 42 
Indoor airing, 37, 60, 153 
Infantile atrophy, 156 

convulsions common in rickets, 463 
See also Convulsions, infantile. 



Infectious diseases causing vomiting, 

Inflation of lungs in asphyxia, 48 
Influenza, 474 

as cause of endocarditis, 304 

danger of complications in, 474 

disinfection after, 476 

preceding otitis, 440 

treatment of, 474, 475 
Inguinal adenitis, 446 

hernia, 415 

reduction of, 415. See also Her- 
nia, inguinal. 
Inhalation of irritating gases, 266 

of steam a cause of laryngitis, 266 
Inhalations in asthma, 279 

in bronchitis, 271 

in bronchopneumonia, 282 

in diphtheria, 323 

in pertussis, 342 
Initial loss in weight, 31 
Institutions a factor in artificial feed- 
ing, 82 

for epileptics, 389 

for mentally defective, 403 
Instructions for mothers, 103 
Insufflations in pertussis, 338 
Insufflator for spreading dusting-pow- 
der, 374 
Intercostal neuralgia, iodin in, 516 
Intermittent treatment in chlorosis, 

463 
in chorea, 386 
in pertussis, 341 
in recurrent bronchitis, 275 
in syphilis, with iodids, 412 
Intertrigo, 424 

Intestinal antiseptics in typhoid fever, 
480 
diseases, acute, effect of climate on, 
522 
etiology of, 198 
prevention of, 197 
treatment of, 201 
hemorrhage rare in typhoid fever, 

483 
infection a cause of obscure eleva- 
tion of temperature, 501 
acute, 208 

active type, 208 
inactive type, 208 
lactic acid bacillus in treatment, 
21 1 
treatment of, 208 
obstruction, 221, 222 

causing vomiting, 187 
parasites, 226-228 
perforation in typhoid fever, 483 
putrefaction as cause of colic, 175 
toxemia, headache in, 376 
in asthma, 279 
in chronic eczema, 425 
in epilepsy, 389 



6l2 



INDEX 



Intraspinous injection of drugs, 397 
Intubation, 324 

displacement of membrane, 327 

in catarrhal croup, 259 

in diphtheria, 326 

in edema of larynx, 326 

in foreign bodies, 267 

in pharyngitis, 328 

in retropharyngeal abscess, 324 

indications for, 325 

method, 325 

necessity for, 327 

plugging tube with membrane, 328 

removal of tube, 328 

results from, 327 

with use of antitoxin, 328 
Intussusception, 223 

causing intestinal obstruction, 29 

mortality of, 223 

reduction of, 223 

stools in, 223 
Inunctions of cacao-butter, 145 

of goose oil, 145 

of ichthyol ointment in chicken-pox, 

347 
of lard, 145 

of mercurial ointment, 409 
of olive oil, 145 
Inverting patient in laryngismus strid- 
ulus, 265 
lodid of potash, administration, 525 
in erythema nodosum, 432 
in hydrocele, 372 
in multiple neuritis, 402 
in peliosis rheumatica, 491 
in pleurisy, 293 
in poliomyelitis, 399 
unpalatable, 525 
lodids, 412 

lodin as counterirritant, 515 
in intercostal neuralgia, 516 
in pleurisy, 293 
in ringworm, 438 

of scalp, 438 
injection in spina bifida, 417 
Ipecac, administration of, 525 
in bronchitis, 273 
in catarrhal laryngitis, 261 
in faucitis, 273 
in pneumonia, 283 
syrup of, 278 
unpalatable, 525 
wine of, 339 
Iron and ammonium citrate, 384, 
462 
and quinin citrate, 133, 165, 175, 301, 

461 
chloride, tincture of, administration 
of, 526 
in incontinence of feces, 231 
citrate, 461, 462 

content of foods, table of, by Bunge, 
461 



Iron extractum ferri pomatum, 301, 
388, 452 
in anemia, 462 
in cardiac disease, 312 
in chlorosis, 463 
in hysteria, 379 
in neuritis, 402 
in persistent adenitis, 447 
in poor appetite, 132 
in tetany, 384 
in tuberculous adenitis, 452 
iodid of, in malnutrition of syphil- 
itic origin, 413 
Irrigation of throat, 258, 333 
in diphtheria, 323 
in peritonsillar abscess, 258 
in quinsy, 254. 
in scarlet fever, 258 
in tonsillitis, 250 
Irritants a cause of gastritis, 188 
Ischiorectal abscess, 230 
Isolation of sick, 314 
Italians and rickets, 463 
Itch, 435. See also Scabies. 
Itching of anus due to pin -worms, 227 

of skin in chicken-pox, 347 
Ivy-poisoning, 433 

Jamas' tubes for cases of pleurisy, 294 
Jaundice of newly born, 50 
obstructive, 459 

stools in, 459 

treatment of, 459 

urine in, 459 
Jaw deformity due to sucking habit, 

454 ^ ^ . 

Jersey cream, percentage of fat in, 94, 

III 
Joint-rheumatism, 485 
Junket, formula for making, 130 

in ileocolitis, 217 

in illness, 140 

when allowed, 136 

Kaoun, cataplasm of, 333, 446 

Key-note position, 555 

Kidney, sarcoma of, a cause of intesti- 
nal obstruction, 222 

Kilmer belt for whooping-cough, 342 
croup-kettle, 361, 521 

Kindergarten chair, 539 

King, experiments on milk contamina- 
tion, 85 

Kissing a bad practice, 28 
in congenital syphilis, 409 
transmission of disease by, 28 

Klebs-Loffler bacillus causing diph- 
theria, 316 

Knee-jerks, increased, in intestinal 
toxemia, 174 

Knotted towel to insure sleeping on 
side, 354 



INDKX 



613 



Kyphosis, exercises for, 547 
rachitic, 466 
with lordosis, exercises for, 551 



Laboratory feeding, 100 
Laborde's method of artificial respira- 
tion, 48 
Lactalbumin of cow's milk, 84 
Lactic acid bacillus, action on milk, 120 
in treatment of acute intestinal 
infections, 211 
Ladder exercises for ataxic children, 

565 
Lakewood for convalescent patients, 

522 
Lamb chop, when allowed, 136 
Lancing gums for teething, 36 
Lanolin, 79 

Laparotomy, indications for, in tuber- 
culous peritonitis, 491 
Lard, 145 

inunctions of, 388 
in malnutrition, 164 
Larkspur in pediculi, 436 
Laryngismus stridulus, 264 
adenoids in, 264 
diagnosis of, 264 
in lymphatic diathesis, 471 
in rickets, 264 

treatment of, 265, 266 
Laryngitis, acute catarrhal, 259 
intubation in, 324 
membranous, 318 
traumatic, 266 
Larynx, abscess of, in diphtheria, 256 
foreign bodies in, 267 
obstruction of, 267 
post-diphtheritic paralysis of, 399 
removal of foreign bodies from, 267 
Late teething, 36 
Lavage, 191 

amount of fluid to be used, 192 

dangers of, 191 

frequency, 191 

in dilatation of the stomach, 195 

in gastritis, 190 

in gastro-intestinal infection, 202, 

203 
in marasmus, 160 
in poor appetite, 193 
in repeated vomiting, 188 
in sugar-indigestion, 106 
indications for. 191 
method of, 191 

rarity of its causing bleeding, 196 
Laxatives after diarrhea, 208 
Lead and opium wash in antitoxin 
urticaria, 321 
in erythema nodosum, 432 
in orchitis, 372 
in rheumatism, 489 
neuritis, 401 



Leaking breasts, 78 

Leg-rubbing, 455. See also Mastur- 
bation. 

Legume diet, 299 

Lemonade in typhoid fever, 479 

Leukemia, 460 

Leukocytosis, effects of Flexner's serum 
on, 393 
in diphtheria, 321 
in fatal cases of diphtheria, 321 

Lice, 436 

Lime-water, 75 

Lips, fissures of, 238 

Lithemic diathesis and asthma, 276 

Lordosis, exercises for, 551 

Low fluids in weaning, 76 

milk diet for intestinal indigestion, 

174 
Lumbar puncture, 396 

disinfection before, 396 

in acute simple meningitis, 390, 391 

in diagnosis, 397 

in treatment, 397 

method of doing, 396 

site for, 396 
Lymphatic glands, enlarged, in diph- 
theria, 249 
in tonsillitis, 249 
Lysins, 527 



Magnesia in bottle-fed, 180, 181 
in chronic ileocolitis, 217 
in colic, 177 
in fissure of anus, 226 
in glandular fever, 494 
Magnesium citrate in acute endocardi- 
tis, 305 
in appendicitis, 223 
in mastitis, 52 
in typhoid fever, 480 
Malaria as cause of multiple neuritis, 
401 
blood in, 476 
diagnosis often made in intestinal 

toxemia, 173 
in delicate child, 149 
Plasmodium of, 476 
quinin in, 477 
recurrence in, 488 
spleen in, 476 
temperature in, 476 
Male fern, oleoresin of, in tape-worm, 

228 
Malignant disease contraindicating 

nursing, 76 
Malnutrition after pertussis, 337 
as cause of chronic rhinitis, 234 
due to exclusive milk diet, 135 
to ileocolitis, 216 
to stomatitis, 234 
from cutting down proteid in consti- 
pation, 180 



6i4 



INDEX 



Malnutrition, gavage in, 143 
in infants, 162 
tardy, non-syphilitic, 164 
of syphilitic origin, 412 
years to get results in, 18 
Malt in tuberculous adenitis, 452 

soup, 109, 163 
Malted foods a cause of malnutrition, 
162 
milk in constipation of nurslings, 
179, 180 
in fissure of anus, 226 



in intestinal indigestion, 



175 



in mucous colitis, 219 
with cocoa, 183 
Maltose, 124 

foods only carbohydrates, 1 24 
Mammary abscess, 52 

due to cracked nipples, 78 
in infants, 52 
Marasmus, 156 

due to chronic gastritis, 190 
in tenements, 160 
Mask in eczema, 423 
Massage for constipation, 180 
in Erb's paralysis, 406 
in hematoma of the sternomastoid, 

418 
in multiple neuritis, 403 
in poliomyelitis, 399 
of abdomen to relieve intestinal 

obstruction, 222 
of breasts, 79 
Mastitis, acute, 80 

a contraindication to nursing, 80 
in newly born, 52 
in young girls, 52 
treatment of, 80 
Mastoiditis, 445 
Masturbation, 455 
brace for, 456 
circumcision for, 456 
cure of, 456 
due to leg rubbing, 456 
to neurotic habit, 455 
to phimosis, 455 
to urine being acid, 455 
more frequent in girls, 455 
night watch in, 456 
Maternal nursing, 66. See sdsoNurs- 
ing mother. 
ability more frequent nowadays, 

66 
advantages of regularity in, 71 
after twelve months, 75 
air and exercise in, 71 
amount proper for nursing, 73 
bad effect of too long continued, 

135 
beginning bottles in, 71 
best age for, 69 
bowel function in, 70 
care of nipples in, 77 



Maternal nursing, conditions forbidd- 
ing, 76 
definite times for, 43 
diet in, 69 

feasible duration of lactation, 68 
frequency of, 7 1 
interfered with by rhinitis, 241 
length of time for each nursing, 73 
management of abnormal milk 

conditions, 74, 75 
menstruation in, 76 
mixed feeding, 75 
prevented by stomatitis, 233 
regularity in, 71 
signs of successful, 72 
of unsuccessful, 72 
temporary discontinuance of, 76 
too rapid, 74 
too weak milk in, 74 
unfavorable factors for, 76 
water before, in fever, 139 
weaning, 76 
Matzoon in typhoid fever, 473 
Meals, definite times for, 43 

number of, in second year, 183 
Measles, 344-346 
care of ears in, 346 

of eyes in, 347 
cause of otitis, 440 
clothing in, 345 
cough in, 346 

danger of bronchopneumonia in, 344 
death-rate in, 344 
delayed rash in, 345 
diet in, 346 

examination of ears in, 346 
frequency of, 344 
fresh air in, 344 
German, 347 
in institutions, 344 
inunction in, 345 
moist air in, 346 
old-fashioned treatment of, 344 
percentages of susceptibility in, 337 
quarantine in, 346 
rhinitis of, 242 
treatment of, 345, 346 
Meat eating in chorea, 385 

in chronic diffuse nephritis, 362 
in rheumatism, 486 
Meckel's diverticulum a cause of intes- 
tinal obstruction, 222 
Mellin's food in constipation, 180, 181 

in fissure of anus, 226 
Membrana tympani, examination of, 
in earache, 440 
paracentesis of, 502 
Meningitis, acute, simple, 390 
convulsions in onset, 380 
diet in, 391 
duration, 392 
etiology, 390 
lumbar puncture in, 390, 391 



INDEX 



615 



Meningitis, acute, simple, management, 
390 
sedatives in, 391 
warm packs in, 391 
cerebrospinal, 392 

serum treatment, 392 
vaccine therapy in, 531 
tubercular, 395 
Meningococcus infection, vaccine ther- 
apy in, 531 
Menstruation and maternal nursing, 76 
Menthol liniment for urticaria, 430 
in articular rheumatism, 489 
in erythema multiforme, 433 
in ointment for eczema, 425 
in rhinitis, 242 
Mercury, 412 

administration of, 409, 410, 411, 412 
albuminate of, 409 
bichloride of, 409 
salicylate, 409 

supplementing interval treatment, 
411 
Method, necessity of, in care of child, 

42 
Micturition, first, 349 

difficult and painful, 350 
Mid-day nap, 43 

for delicate children, 155 
for nursing mother, 7 1 
in cure of hysterical children, 379 
in tardy malnutrition, 164 
Miliaria, 439 

Milk a cause of constipation, 180, 182 
a factor in acute intestinal diseases, 

199 
action of, on stomach secretions, 63 
butter, 120 
certified, 88 

contaminated by cow's udder and 
body, 86 
by manure, 84 
by openings in pails, 86 
by pouring, 85 
by standing, 85 
by utensils, 85 
cooked, a cause of constipation. 180 
cow's, 83-1 1 I 

adaptation of, 92 
by alkalies, 106 
by cereal gruels, 108 
by malt soup extract, 109 
by peptonizing, 109 
by sodium citrate, 107 
by whey feeding, 107 
bottled, 88 

care after sterilizing and pasteur- 
izing, 116 
casein of, a cause of intolerance 

for, 112 
cooling, 91 

cost of producing clean, 88 
curds of, 107, 109 



Milk, cow's, curds of, effect of alkalies 
on, 63 
of cereal gruels on, 108 
of peptonizing on, 109 
of sodium citrate on, 107 
of sterilization on, 115 
fat of, adaptation of, 107 
affected by cow's diet, 83 
child's digestive capacity for, 

107 
modification of, 93 
percentage of, compared to that 
of human milk, 92 
lactalbumin of, 84 

effect of sterilization on, 115 
lactic acid bacillus in, 1 20 
lactose of, 84 

modification of, 93 
lime salts, effect of sterilization on, 

,115 
mixtures, resuming, after con- 
densed milk, 113 
with cream, 95, 96 
modification of, 92, 93 

by cream and milk mixtures, 

95, 96 
by dilution, 93 

and adding lactose, 94 
by laboratory methods, 100 
by skimmed milk mixtures, 96 
by top-milk methods, 98 
peptonization of, 119, 120 
proteid of, a cause of colic, 1 76 

adaptation of, 107 
reasons for using, in artificial feed- 
ing, 83 
skimmed, a substitute for whole 
milk in fat incapacity, 151 
in rectal feeding, 147 
mixtures of, 96 
solids of, 84 
crusts, 426 

dairy, percentage value of, 92 
diet, exclusive, 134 
in nephritis, 357 
in scarlet fever, 329 
drinking, excessive, cause of loss of 

appetite, 131 
examination in breast fed, 73 
fermented, 120 
food constituents of, 63 
for traveling, 122 
general properties of, 63 
habit, 151 

and loss of appetite, 132 
and malnutrition, 132 
herd, 83 
human, composition of, 64 

affected by sore nipples, 78 
exact reproduction of, impossible, 

58. . 
examination of, 64 

fat of, 64 



6i6 



INDKX 



Milk, human, microscopic examination 
of, 65 
percentage composition of, 92, 1 23 
percentages of food constituents 
of, 64 

importance of, in diet of child, 150 

in acute intestinal infection, 211 

in diet of the nursing mother, 70 

in ileocolitis, 208, 212 

in mucous colitis, 219 

in nephritis, 362 

in tetany, 383 

in urticaria, 430 

malted. See Malted milk. 

market, 199 

standards of, 87 
unsafe in summer, 199 

maximum amount of, after first 
year, 151 

modified, 92 

raw, in constipation, 180 

resuming, after diarrhea, 172, 207 

selected, 199 

sour, 120 

stopping, in acute intestinal infec- 
tion, 208 

supply in country, 514 

to be avoided in typhoid fever, 479 
Milking, directions for, 200 
Minced beef, when allowed, 136 
Mineral substances in foods, function 

of, 62 
Mixed feeding, 75 

in wet-nursed babies, 81 

infections of throat, 249 

treatment, 412 
Modern school system, pernicious, 60 
Modified milk, definition of, 92 
Moist air in care of measles, 346 

skin predisposing to colds, 240 
Molar teeth, time of appearance of, 

36 
Molasses and water injection for fecal 

impaction, 273 
Mongolian idiot, 405 
Morphin in acute gastro-intestinal 
infection, 203 

in convulsions, 381 

in cyclic vomiting, 495 

in meningitis, 391 

in pronounced vomiting, 190 

unnecessary in asthma, 279 

with atropine, ratio of doses, 190 
Mortality from summer diseases, 171 

statistics valueless in regard to 
nutritional errors, 82 
Mosher's kindergarten chair, 539 
Mother, education of, 17, 21, 172 

ignorance of, due to physician, 43 

nursing. See Nursing mother. 
Mountains, 514 

Mouth breathing due to adenoids, 448 
to hypertrophied tonsils, 252 



Mouth portal of entry of pyogenic 
bacteria, 49 
temperature in children, 497 
toilet, 233, 234 
Mucous colitis, 218 
diet in, 218 
stools in, 218 
Multiple neuritis due to arsenic, 401 
to exanthemata, 401 
to lead, 401 
to malaria, 401 
to phosphorus, 401 
Mumps, 348 

complicated with nephritis, 348 
rare cause of deafness, 444 
with orchitis, 372 
Muscular twitchings in acute intestinal 

infection, 210 
Musk as a heart stimulant, 290 
Mustard as a counterirritant, 515 
baths, 30, 273, 283, 380 
leaves, 189 

plasters, 272, 279, 282, 293 
Mutton broth, formula for preparing, 

129 
Myocarditis, 308 

after diphtheria, 399 
endocarditis, 307 
pneumonia, 307 
scarlet fever, 307 
diet in, 308 
rest in, 309 
sitting up after, 309 
stimulation in, 308 
Myxedema, infantile, 467 



Napkin washer, 20 

Nasal discharge, chronic, due to ade- 
noids, 448 
hemorrhage due to adenoids, 246 
to ulcerations of nasal septum, 
246 
treatment of, 246 
Nasopharynx, inflammation of, as 

cause of asthma, 276 
Negro, rickets in, 463 
Nephritis, acute, bathing in, 358 
bowel function in, 358 
colon flushing in, 360 
diet in, 358 
hot packs in, 360 
in acute illness, 168 
treatment of, 357-359 
urea in, 361 

uremic convulsions in, 361 
chronic diffuse, 362 
baths in, 362 
beef foods in, 135 
climate in, 363 
clothing in, 363 
diet in, 362 
exercise in, 362 



INDEX 



617 



Nephritis, chronic diffuse, headache in, 
376 
in mumps, 348 
interstitial, 365 
maternal nursing contraindi- 

cated by, 76 
rare under three years, 362 
secondary to acute, 362 
treatment, 362, 363 
vomiting caused by, 187 
post-scarlatinal, 335 
Nerve grafting, 407 
Nervous cough, 268 

disorders of childhood, 173 
Nettle-rash, 429 

Neurasthenia diminishing among wo- 
men, 64 
Neuritis, multiple, 401 
Neurotic eczema, 425 
New Mexico for tuberculosis, 523 
New York County Medical Society, 

Milk Commission of, 88 
Newly born, affections of, 45-57 
asphyxia of, 48 
atelectasis of, 51 
cephalhematoma of, 50 
granuloma of, 53 
hemorrhagic diseases, 53 
jaundice in, 50 
mastitis in, 52 
sepsis in, 49 
tetanus of, 56 
time for first bath in, 29 
umbilical polyp of, 51 
Night bottle, 99 

breaking from, 99 
terrors, 38 2 

watch in masturbation, 458 
Nipple, care of, 23, 77 
cracked and fissured, 78 
depressed, 79 

shield in cracked nipples, 78, 79 
Nitrate of potash in asthma of older 

children, 279 
Nitre, sweet spirits of, in cough of 

measles, 346 
Nitric acid in noma, 237 

in pertussis, 339 
Nitrogenous food in acid urine, 352 
Nitroglycerin contraindicated in myo- 
carditis, 309 
in cyanosis, 284, 290 
Nitrous oxid gas and ether in adenoids, 
450 
danger signals in administra- 
tion, 517 
under two years to be used with 

caution, 517 
with caution, 517 
Noma, 236 

Nose, portal of entry of pyogenic bac- 
teria, 49 
Nursery, airing of, 24 



Nursery, changing napkins in, 24 
floor of, 24 
fresh air in, 25 
maid, gonorrhea in, 23 
physical examination, 23 
schools for training, 23 
tuberculosis in, 23 
requirements of, 24, 25 
shades for, 25 
steam heat in, 25 
sweeping in, 24 
temperature of, 153 
ventilation of, 24 
Nursing. See Maternal nursing. 
bottle, care of, 23 

mother, amount of food necessary 
for, 69 
constipation in, a cause of colic in 

child, 176 
diet of, 69 

mid-day rest for, 71 
rules for, 69 
requirements of, 23 
Nutrient enema, 119, 147 
in cyclic vomiting, 494 
in persistent hematemesis, 196 
in post-diphtheritic paralysis, 401 
suppositories, 144 
Nutrition a factor in treatment of tu- 
berculosis, 299 
and growth, 57-162 
defective, a cause of many deaths, 82 
important in tuberculous peritonitis 
492 
Nutritional disorders of childhood, 

indigestion a factor in, 173 
Nux vomica, tincture of, 71, 133, 459, 
463, 480 
in constipation, 175, 185 
in malnutrition of syphilitic 

origin, 413 
in mucous colitis, 219 
in tardy malnutrition, 165 
in tuberculosis, 301 
Nystagmus associaed with gyrospasm, 
383 



Oatmeal, 151 

a cause of urticaria, 430 

gruel in the cure of constipation, 182 

when allowed, 136 
jelly, 135 

formula for preparing, 1 29 
water, formula for preparing, 130 
in constipation of bottle-fed, 180 
when allowed as a cereal, 136 
Obesity, diet in, 460 
Obstetrical paralysis, 406 
O'Dwyer, Joseph, M. D., inventor of 

intubation, 324 
Oil injections in constipation of bottle- 
fed, 181 



6i8 



INDEX 



Oil injections in malnutrition of in- 
fants, 164 
in prolapse of rectum, 229 
inunctions in chronic ileocolitis, 218 
in marasmus, 162 
in measles, 345 
in scarles fever, 332 
of cade in collodion, 423 
of wintergreen in rheumatism, 489 
treatment for constipation, 165, 175, 
179, 183, 185, 226, 230, 275, 389 
Oiled silk jacket, 281, 288 
Ointments in cracked nipples, 78 

in eczema, 423 
Oleoresin of male fern in tapeworm, 

228 
Oleum phosphoratum in rickets, 466 
Olive oil in constipation, 164, 165, 
181 
in contagious impetigo, 431 
in mucous colitis, 218 
in seborrhea capitis, 426 
rub, 145, 151 
Omelet, when allowed, 137 
Open windows a cause of catching 

cold, 241 
Operation for appendicitis, 223 
for bow-legs, 466 
for cleft palate, 418 
for hare-lip, time of, 418 
for pyloric stenosis, 197 
for rectal prolapse, 229 
for spina bifida, 417 
for tuberculous adenitis, 452 
for umbilical hernia, 416 
Ophthalmic reaction in tuberculosis, 

299, 533 
Opium and its derivatives in diabetes, 

374 
contraindicated in colic, 177 
in diarrhea, 203 

of typhoid, 481 
in gastric indigestion, 190 
in hysteria, 379 
in ileocolitis, 213 
narcosis, gavage in, 143 
Opsonic index, 528 
Opsonins, 527 
Optical delusions in intestinal toxemia, 

174 
Orange juice in constipation of bottle- 
fed, 181 
in scurvy, 467 
Oranges, when allowed, 137 
Orbicularis oris, hypertrophy due to 

thumb-sucking, 454 
Orchitis complicating mumps, 348, 372 
Osteomyelitis, vaccine therapy in, 530 
Otitis media, 440 

a cause of facial paralysis, 403 
of obscure elevation of temper- 
ature, 501 
of persistent deafness, 444 



Otitis media, danger of, from throat 
irrigations, 323 
in influenza, 475 
in measles, 346 
in scarlet fever, 334 
suppurative, 444 
vaccine therapy in, 530, 531 
Outdoor exercise after pleurisy, 293 
Outdoors, going out, 37, 153 
Overeating as cause of dilatation of 
stomach, 194 
of vomiting, 187 
during second year, 134 
effect of, on milk, 75, 133 
in nurslings, 74 
Overwork in exercises, 59 
Oxygen in atelectasis, 52 

in pneumonia, 286 
Oxyuris vermicularis, 227 



Pacifier, 454 

Packs. See Cool pack. 

Pad for umbilical hernia, 416 

Pain a symptom of pleurisy, 292 

counterirritants for, 515 

in chest often absent in lobar pneu- 
monia, 287 

in otitis, 441 

in peritonitis, 491 
Pancreas, starch-converting enzyme 

of, 128 
Paper napkin for tuberculosis sputum, 

301 
Paracentesis of membrana tympani 
in chronic otitis media, 444 
indication for, 442 
Paralysis, Erb's obstetrical, 406 

infantile, 398 

of larynx after diphtheria, 399 

of pharynx after diphtheria, 399 
Paraphimosis, treatment of, 370 
Paraplegia, 404 
Parasiticide for ringworm of the scalp, 

437 

Paregoric, 213, 303, 346 

Park, Dr. William Hallock, experi- 
ment in summer diarrhea, 200 

Parotitis, epidemic, 348. See also 
Mumps. 

Parsons on bacteria and cow's milk, 84 

Pasteurization of milk, 115 

Patent medicines, 524 

Patient, first examination of, 39 

Pavor diurnum of intestinal origin, 173 

Peaches, when allowed, 138 

Pears,* when allowed, 137 

Peas, when allowed, 137, 151 

Pediculi, treatment of, 436, 437 

Peliosis rheumatica, 490 

Pemphigus due to syphilis, 432 
neonatorum, 431 

Peppermint water as a vehicle, 526 



INDEX 



619 



Pepsin, essence of, for making junket, 
130 
whey, 130 
in stomach of young child, 63 
Peptonized milk, 119 
in adaptation, 109 
in difficult feeding, 112 
in gavage, 143 
in rectal feeding, 146 
in tetany, 384 
processes, 119 
Peptonizing tubes, 120 
Percentage composition of foods, 62 
Perforating ulcer of stomach, rarity of, 

195 

Pericarditis as cause of pleurisy, 293 
due to rheumatism, 303 
rheumatic, treatment of, 304 

Pericardium, incision of, 304 

Pericranial hemorrhage in newly born, 

54 
Perimastoiditis as sign of mastoiditis, 

445 
Periodic temperature in empyema, 476 
in fatigue, 476 
in influenza, 476 
in intestinal infection, 476 
in malaria, 476 

not due to malaria, but cured by 
quinin, 501 
Periostitis of tibia, syphilitic, 411 
Peristalsis, visible, in tuberculous peri- 
tonitis, 492 
Peritonitis, acute general, 491 

infective, causing intestinal ob- 
struction, 222 
tuberculous, 491 

causing intestinal obstruction, 221 
fever in, 492 
rest in bed in, 492 
Peritonsillar abscess, 252 

irrigation of the throat in, 258 
peptonized milk by gavage in, 119 
Permanent teeth, order of their appear- 
ance, 35 
Permanganate of potash in gonor- 
rhea, 372 
Peroxid of hydrogen in noma, 237 
Persistent adenitis often tubercular, 

447 . 
operation on, 447 
cough after intubation, 327 
due to adenoids, 268 

to adherent pleura, 268, 269 
vomiting diagnosed as gastritis, 188 
due to congenital pyloric stenosis, 

197 
in acute gastric indigestion, 188 
Pertussis, 336 

age of occurrence, 336 
antipyrin and bromid in, 340, 341 
belt for, 342 
bronchopneumonia in, 337 



Pertussis causing hernia, 415 
vomiting, 187 

complications of, 337 

convulsions in, 337 

diagnosis of, early, 337 

extravasations of blood in, 338 

fresh air in, 342 

greatest susceptibility to, 337 

incubation period of, 336 

malnutrition in, 337 

management of, 338 

percentage of susceptibility to, 337 

quinin in, 339 

season of occurrence, 336 

steam inhalations in, 342 

transitory deafness in, 337 

tuberculosis in, 337 

versus laryngismus stridulus, 265 

without a whoop, 337 
Pharyngitis, 248 
Pharynx, post-diphtheritic paralysis 

of, 399 
Phenacetin, 499 

in bronchopneumonia, 283 
in influenza, 474 
in typhoid fever, 481 
Phimosis, 369 

as cause of convulsions, 369 
causing difficult micturition, 350 
incontinence of urine, 352 
retention, 351 
deterrent to growth, 149 
in epileptics, 389 
in masturbation, 455 
treatment of, 401 
Phosphorus as cause of multiple neu- 
ritis, 401 
Physical examination, frequency of, 

in measles, 346 
Pin-w^orms, 227 
Plasmodium malariae, 476 
Plaster of Paris, 466 
Play in chorea, 385 
Pleura, adherent, as cause of cough, 

268, 269 
Pleurisy, acute primary non-rheumatic, 
292 
dry, 292 

iodin in, 516 
secondary, 292 
tubercular, primary, 294 
with effusion of rheumatic origin, 488 
of tuberculous origin, 294 
Pleuritic adhesions, 294 
effusions, 293 

pain, counterirritation in, 515 
Pneumococcus infection, vaccine 

therapy in, 531 
Pneumonia, laroncho-, 280-286 
bowel function in, 281 
complicating influenza, 475 
measles, 344 
pertussis, 337 



620 



INDEX 



Pneumonia, broncho-, diet in, 281 
drugs in, 283 
fever in, 271 
hydrotherapy, 284 
hygiene, 281 
inhalations, 282 
oxygen in, 286 
central, 286 
lobar, 286-292 
alcohol in, 520 
as cause of endocarditis, 310 

of pleurisy, 293 
complicated by multiple neuritis, 

401 
convulsions in onset of, 380 
crisis in, 287 
delayed signs of, 286 
headaches in onset of, 376 
onset of, 286 
physical signs of, 286 
treatment of, 287 
vaccine therapy in, 531 
Podophyllin in cure of constipation, 185 
Poisoning from impure bismuth, 205 

from rhus toxicodendron, 433 
Poliomyelitis, acute anterior, 398 
drugs in, 399 
electricity in, 399 
massage in, 399 
prevention of deformity, 399 
treatment in acute stage, 398 
Polyuria, absence of, in glycosuria, 

343, 366 
Position for defecation in rectal pro- 
lapse, 229 
Post-cervical glands, enlarged, in Ger- 
man measles, 347 
Post-diphtheritic paralysis, 399-401 
age of occurrence, 399 
difficult swallowing in, 399 
gavage in, 401 
heart action in, 399 
irregularity of pulse in, 399 
of extremities, 399 
of larynx, 399 
of pharynx, 399 
rectal feeding in, 401 
treatment of, 400, 401 
Postural treatment of rectal prolapse, 

229 
Posture and breathing, 537 
Potassium chlorate in tonsillitis, 251 
citrate, 367 

in acute pyelitis, 368 
in eczema due to hyperacidity, 421 
iodid, 411, 412. See also lodid of 
potash. 
Potato, baked, when allowed, 137 

stewed, when allowed, 137 
Pott's disease secondary to tubercu- 
lous peritonitis, 492 
Poultice, flaxseed, 292 
and mustard, 292 



Poultry, when allowed, 137 
Predigested cereals in gavage, 143 
foods during illness, 1 39 

in lobar pneumonia, 291 
Pregnancy a contraindication to lacta- 
tion, 76 
Premature infants, 45-47 

air for, 45 

cause of prematurity and effect on 
life, 45 

feeding of, 47 

length of life in, 45 

warmth, 45, 46 
Prepuce, adherent, treatment of, 369 
Prescriptions for laboratory feeding, 

lOI 

of exercise, 535 
Pressure in hemorrhagic diseases of the 
newly born, 54 
of water in reduction of intussuscep- 
tion, 21 
Prevention of intestinal diseases of 

summer, 197 
Prickly heat in overclad children, 439 

starch bath in, 31 
Prolapse of rectum, 228 
operation for, 229 
treatment of, 229 
Proprietary foods as cause of rickets, 
464 
of scurvy, 467 
as sole diet, 59 , 

disadvantages of those not con- 
taining milk, 123 
dried mUk foods, 123 
standard for selecting, 123 
Protection against colds, 155 
Proteid content of intestine as cause 
of intestinal toxemia, 174 
incapacity as cause of colic, 175 
indigestion, signs of, 100, 106 
minimum, for normal growth, 180 

in proprietary foods, 123 
of cow's milk, 83 

adaptation of, 105-111 
modification of, 93 
Proteids, essential ingredients of foods, 
61 
functions of, 62 
of milk as cause of colic, 175 
where found, 61 
Prunes, stewed, when allowed, 136 
Pseudodiphtheria bacillus, vaccine 

therapy in, 531 
Pseudoleukemic anemia of von Jaksch, 

460 
Pseudomembrane in tonsillitis, 249 
Puddings, when allowed, 136 
Pulse, irregularity of, after diphtheria, 

.399 

in myocarditis, 308 
Purees of peas, beans, and lentils, 59 
Purpura, causes of, 471 



INDEX 



621 



Purpura, fulminant, 194 
in peliosis rheumatica, 490 
in pyemia, 471 
in septicemia, 472 
prognosis in, 472 

Putrefactive bacteria and cow's milk, 

84 
Pyelitis, acute, 368 
Pyemic infection of nose, 246 
Pyloric spasm, 196 

stenosis, congenital, 196 

as cause of vomiting, 196 

operation for, 196 

stomach wave in, 196 

treatment of, 197 
Pyrexia in acute illness, 169 

Quarantine, 314-316 

in measles, 346 
Quassia, infusion of, in thread-worms, 

227 
Quiet in sick-room, 331 
Quincke needle for lumbar puncture, 

396 
Quinin bisulphate, 526 

administration of, 526 

by hypodermic injection, 477 
by inunction, 477 
by mouth, 477 
by rectum, 477 
as cause of urticaria, 430 
in finger sucking, 454 
in lobar pneumonia, 291 
in malaria, 476 

in malnutrition of syphilis, 413 
in mucous colitis, 219 
in neuritis, 402 
in tuberculosis, 407 
in typhoid fever, 481 
Quinsy, 252. See Abscess, periton- 
sillar. 

Rachitis, 463-467. See Rickets. 
Raspberry, syrup of, as vehicle, 234, 

340 
Raw milk vs. sterilized or pasteurized 

milk, 116 
Records of cases, 39 

of daily illness, blank form for, 63 
Rectal bleeding suggesting polypus, 231 
feeding, 145-147 

after acute gastro-intestinal indi- 
gestion, 189 
in acute illness, 169 
in cyclic vomiting, 494 
in diphtheria, 324 
in meningitis, 391 
of peptonized skimmed milk, 119 
substances contraindicated in, 146 
irrigation in typhoid fever, 482 
medication, method of giving, 266 
sodium salicylate by, 304 



Rectal polypus, 231 

temperature in child, 497 
tube, size for, 220 
Rectum, examination of, in constipa- 
tion, 181 
prolapse of, 228 
Recurrence in chorea, 387 
Recurrent bronchitis, 274 
Red meat as cause of rheumatic 
attacks, 486 
in asthma, 279 
in cardiac disease, 310 
in habit spasm, 387 
in recurrent bronchitis, 275 
to increase fat in milk, 178 
Reflex eczema, 425 
Regurgitation, persistent, 106 
Removal from home in chorea, 385 
of adenoids in chronic nasal dis- 
charge, 245 
in mouth-breathing, 245 
in nasal hemorrhage, 246 
Rennet, essence of, for making junket, 

130 
Resorcin in pertussis, 338 

in seborrhea capitis, 426 
Respirations in lobar pneumonia, 286 
Rest after g\^mnastic therapeutics, 436 
in acute endocarditis, 305 
in anemia, 461 
in chorea, 384 

in diphtheritic paralysis, 400 
Restlessness in broncho-pneumonia, 

2S3 
Results in pediatrics often delayed, 18 
Retention of urine, 350, 351 
Retropharyngeal abscess, 254 
adenitis, 254, 451 

due to caries of cervical vertebrae, 

258 
gavage in, 119 
intubation in, 324 
irrigation of throat in, 258 
Revaccination, 507 
Rheumatic diathesis, 252, 485 

in hypertrophy of tonsils, 252 
family history in cardiac disease, 310 
pain, chloroform liniment in, 516 
pleurisy, 293, 488 
Rheumatism, acute articular, chloro- 
form liniment in, 516 
factor in asthma, 276 
in chorea, 384 
in cyclic vomiting, 495 
as cause of endocarditis, 304 
of erythema nodosum, 421 
of multiple neuritis, 403 
of recurrent bronchitis, 4S6 
growing pains due to, 48 5 
importance of, in family history, 39 
in habit spasm, 387 
joint pains due to, 485 
management of case of, 486 



622 



INDKX 



Rheumatism, occurrence of, 485 
oil inunctions in, 144 
pleurisy due to, 488 
red meat in, 486 
sugar in, 486 
tonsillitis in, 485 
treatment of, local, 489 

between attacks, 489 
underlying recurrent bronchitis, 275 
Rhinitis, acute, as cause of chronic 
rhinitis, 244 
in onset of measles, 242 
interferes with nursing, 241 
of congenital syphilis, 410 
versus diphtheria, nasal, 242 
rhinitis, syphilitic, 242 
Rhubarb and calomel in pharyngitis, 
248 
and soda in chronic eczema, 425 
in faucitis, 248 
in intestinal indigestion, 175 
in jaundice, 459 
Rhus toxicodendron, poisoning from, 

433 
Rice as cereal, when allowed, 135 

in typhoid fever, 479 

water after gastro-intestinal infec- 
tion, 203 
formula for making, 129 
Rickets, 463-467 

a cause of laryngismus, 264 

and infant mortality, 463 . 

due to sterilization of milk, 115 

in gyrospasm, 383 

in infantile convulsions, 463 

in laryngismus stridulus, 264, 463 

kyphosis, 466 

predisposing to catching colds, 241, 

463 
to convulsions, 380 

Ringworm, 438 
of scalp, 437, 438 

Roast beef, when allowed, 136 

Rochelle salts in caked breasts, 76 

Roof gardens, 153 

Rosary, rachitic, 463 

Round-worms, 226 

Rubbing through teeth, 36 

Rubella, 347. See also German mea- 
sles. 

Rules for care of infants at New York 
Babies' Hospital Dispensary, 103, 
511 



Saccharin as substitute for sugar in 
rheumatism, 486 
in cure of obesity, 460 
in place of sugar in asthma, 277 

Salicylate of soda, administration of, 

525 
by rectum, 304 
an unpalatable drug, 524 



Salicylate of soda, dangers of, 19 

dosage of, 486 

in antitoxin urticaria, 321 

in asthma, 280 

in cardiac disease, 310 

in chorea, 385 

in cyclic vomiting, 495 

in endocarditis, 305, 306 

in erythema multiforme, 433 

in habit spasm, 388 

in influenza, 474 

in multiple neuritis, 402 

in pericarditis, 304 

in pneumonia, lobar, 291 

in recurrent bronchitis, 274, 275 

in urticaria, 430 

nausea and vomiting from, 489 
Salicylic acid in dusting-powder, 53 

with tar locally in eczema, 425 
Saline enema in sepsis of newly born, 50 
solution, normal, in colon flushing, 

518 
Salivation in stomatitis, 232 
Salt bath, 152 

during illness, 505 

in chronic ileocolitis, 218 

in habit spasm, 388 
water for sponging, 502 
Sanitarium treatment, advantages of, 

523 
for tuberculosis, danger of, 523 
Santonin in worms, 226, 227 
Sarsaparilla, 140 
Scabies, 435 
Scales for weighing, 33 
Scarification in erysipelas, 483 
Scarlatina, 328, 335 

as cause of endocarditis, 304 
of general peritonitis, 491 
of otitis, 440 
clothing during, 329 
complicated by adenitis, 333 
by arthritis, 335 
by deafness, 334 
by nephritis, 335 
by neuritis, multiple, 401 
by otitis, 334 
convulsions in onset of, 380 
death-rate in, 329 
desquamation in, 332 
diet in, 329, 330 
fever in, 331 

headache in onset of, 376 
irrigation of throat in, 258 
laxatives in, 330 
management of, 328 
serum treatment of, 330 
sick-room in, 329 
urine examination in, 329 
vaccine therapy in, 530 
with myocarditis, 301 
Scarlatinal nephritis, 362 
Scars from chicken-pox, 347 



INDEX 



623 



School children, diet suitable for, 59 
for delicate children, 155 
hygiene, 541 
in chorea, 385 
in habit spasm, 388 
in malnutrition, 164 
Schultze's method for artificial respira- 
tion, 48 
Scoliosis, 551 

Scorbutus, 467. See also Scurvy. 
Scraped beef, 151 

formula for preparing, 1 29 
in chronic ileocolitis, 217 
in typhoid fever, 479 
when allowed, 135 
Scurvy due to proprietary foods, 123 
to sterilization of milk, 115 
orange-juice in, 467 
Seashore, 153 

aggravating catarrh, 514 
in asthma, 521 
Season as factor in artificial feeding, 104 

in marasmus, 159 
Seborrhea capitis, 426 

intertrigo, 427 
Seidlitz powder, 305 
Separation from family in hysteria, 378 
Sepsis in newly born as a cause of 
hemorrhagic disease, 54 
location of process, 49 
portal of entry of, 49 
treatment of, 49 
Septicemia, vaccine therapy in, 530 
Serum treatment of cerebrospinal 
meningitis, 392 
method, 395 
of diphtheria, 316 
of scarlet fever, 330 
Shampoo of olive oil and kerosene, 437 
Sherry wine, 132 

in marasmus, 159 
in tuberculosis, 301 
Shot-bag exercises, 542 
Showing off, pernicious, 379 
Sick-room, 43 

in acute illness, 167 
in bronchopneumonia, 281 
in grippe, 476 
in lobar pneumonia, 288 
in measles, 345 
in scarlatina, 329 
Silver nitrate in cord-stump, 26 
in cracked nipples, 78 
in fissure of anus, 226 

of the lips, 238 
in granuloma, 53 
in ulcer of frenum of tongue, 238 
Sitting, posture in, 537 

up, time for, 26 
Skimmed milk in acute intestinal indi- 
gestion, 177 
in convalescence from ileocolitis, 
215 



Skimmed milk in obesity, 460 

in recovery from diarrhea, 206 
in rectal feeding, 147 
mixtures, 96 

pancreatized, in enemata, 146 
percentage equivalents of, 96 
Skin as portal of entry for pyogenic 
bacteria, 49 
care of, in chicken-pox, 347 
diseases of, 420-439 
irritant lesions, in epilepsy, 389 
lesions affecting growth, 149 
Sleep, amount of necessary, 27 
disturbed, causes of, 28 
induced by mustard-baths, 30 
talking in, due to intestinal toxe- 
mia, 174 
Sleeping alone, 25 
late, 165 
posture for, 538 

rooms for delicate children, 153 
Sleeplessness in pertussis, 341 
Snuffies, 242 
Soap, kitchen, for ringworm of scalp, 

437 
Soapsuds enema. See Enema. 
Soda bath, 31 

in eczema, 423 
in prickly heat, 439 
mint in colic, 177 
Sodium biborate in angioneurotic 
edema, 408 
in tonsillitis, 250 
bicarbonate in grippe, 474 
bromid. See Bromid of soda. 
carbonate, solution of, for diapers, 29 
citrate, 107, 112 

sulphate in acute gastro-intestinal 
infection, 203, 209 
Soft-boiled eggs in typhoid fever, 479 
Soiled napkins, care of, 25 
Sore mouth, 233. See also Stomatitis. 
Soups, when allowed, 137 
Sour milk, 1 20 
Spasm, habit, 387 
Spasmus nutans, 382 
Spina bifida, 417 
Spinach, when first allowed, 136 
Spinal ataxia, exercises for, 557 
canal, injection of drugs into, 391 
douche, 151 

in recurrent bronchitis, 276 
Spirit of mindererus, 498 
Splints after anterior poliomyelitis, 399 

in dactylitis, 493 
Spoiling a sick child, 331 
Sponge bath in acute illness, 167 
in diphtheria, 324 
in fever; 498 
in lobar pneumonia, 289 
in measles, 345 
in mumps, 348 
in scarlet fever, 503 



624 



INDEX 



Sponge bath in summer, 509 
never to be used on a baby, 29 

Sprays, 323 

of albolene and menthol for rhinitis, 
242 

Spring water, 514 

Sprue, 235 

Square head, 463 

St. Vitus' dance, 384. See also Chorea. 

Standard of milk for infant feeding, 88 

Staphylococcus albus in pemphigus, 

431 
infection, vaccine therapy in, 529 
Starch, addition of, to food, beginning, 

134 
and opium enema in ileocolitis, 215 
bath, 31 

in prickly heat, 440 
digestion, in young infants, 126,127 
feeding, 126-129 
in ileocolitis, 217 
Starvation treatment of vomiting, 189 
Status lymphaticus, 471 
Steak, when allowed, 137 
Steam inhalation, 271 
in bronchitis, 271 
in bronchopneumonia, 271, 282 
in catarrhal croup, 262 
in pertussis, 342 
Sterilization of milk, effect of, 115 

in feeding dispensary patients, 115 
methods of, 115 
Sterilized milk as cause of scurvy, 467 
Sternomastoid, hematoma of, 518 
Stertorous breathing in retropharyn- 
geal abscess, 255 
Stimulation in acute illness, 170 
Stock gruels, 479 

prescriptions, 524 
Stomach cough, 268 

development of, by milk, 63 
feeding, substitutes for, 144 
in chronic gastro-enteritis, 195 
in newly born, 195 
inflammation of, as cause of vomit- 
ing, 187 
ulcers of, causing hematemesis, 194, 

195 
vomiting, 187 
washing, 191. See also Lavage. 
wave in congenital pyloric stenosis, 
197 
Stomatitis, 232 
aphthous, 232 
catarrhal, 232 
improper care of mouth as cause of, 

232 
mycotic, 235 
treatment of, 234 
ulcerative, 232 
Stone in bladder, 367 
Stools, green, as signal for giving castor 
oil, 171 



Stools, green, due to high fat, 72 
to indigestion, 106 
immediate treatment of, 200 
in bronchopneumonia, 281 
in congenital stenosis of pylorus, 197 
in difficult feeding, 112, 113 
in fissure of anus, 225 
in ileocolitis, 212, 216 
in intussusception, 223 
in typhoid fever, 480 
in unsuccessful maternal nursing, 
.72 
Straight-jacket in eczema, 423, 429 
Strapping chest in pleurisy, 292 

for ventral hernia, 417 
Straus laboratory milk, 199 

milk charity, 103 
Strawberries as cause of urticaria, 430 
Streptococcus causing purpura, 472 
infection, vaccine therapy in, 530 
throat, clinically like diphtheria, 317 
usually cause of retropharyngeal 
abscess, 254 
String-beans, when allowed, 137 
Stringed screen for gymnastic thera- 
peutics, 535 
Strophanthus, tincture of, abuse of, 313 
in bronchopneumonia, 287 
in cardiac disease, 313 
in diphtheria, 324 
in endocarditis, 305 
in gastro-intestinal infection, 202 
in ileocolitis, 213, 214 
in intestinal infection, 210 
in lobar pneumonia, 289 
in myocarditis, 307 
in nephritis, 361 
in pericarditis, 303 
in postdiphtheritic neuritis, 400 
in scarlet fever, 332 
in typhoid fever, 482 
Striimpell, quoted, 385 
Strychnin, administration of, 526 
after diphtheria, 400 
contraindicated in acute intestinal 

infection, 210 
dosage in myocarditis, 307 
in bronchopneumonia, 284 
in diphtheria, 324 
in enuresis, 356 
in lobar pneumonia, 290 
in mucous colitis, 219 
in neuritis, 402 
in scarlet fever, 332 
in typhoid fever, 482 
Study, amount of, for neurotic children, 

Stupes, turpentine, in colic, 516 
Styes, vaccine therapy in, 530 
Styptics in hemorrhagic diseases of the 

newly born, 54 
Substitute feeding, 82 See also Feed- 
ing, artificial. 



INDEX 



625 



Sudden death due to myocarditis, 308 

to status lymphaticus, 471 
Suffocation from foreign bodies in 

larynx, 267 
Sugar, administration of, causing glyco- 
suria, 365 

capacity, low, in chronic gastritis, 
190 

content of cow's milk, 83 

in asthma, 277-280 

in cardiac disease, 310 

in chorea, 385 

in cyclic vomiting, 515 

in obesity, 460 

indigestion, 106 

signs of excess, in food, 106 

water between nursings, 72 
Suggestion a factor in children's com- 
plaints, 377 
Sulphid of calcium in furunculosis, 

435 
Sulphur in administration of bismuth, 
205, 213 
in ringworm of scalp, 437 
ointment in scabies, 435 
Summer, bathing in, 511 

care of feeding bottles in, 512 

of milk in, 511 
clothing in, 511 

diarrhea. See Indigestion, acute in- 
testinal. 
mortality in, 171 
fresh air in, 511 
instructions for, 509 
resorts, 513, 514 

for delicate children, 154 
sleeping, 511 

undigested stools during, 509 
Suppositories, 179 

in constipation, 181 
Suppression of urine, 351 
in acute illness, 169 
treatment, 351 
Suppuration of cephalhematoma, 50 
of glands, treatment of, 447 
vaccine therapy in, 530 
Suprarenal extract in purpura, 472 
Suspensory bandage after orchitis, 372 
Swallowing, difficulty, after diphtheria, 
400 
due to retropharyngeal abscess, 

.255 
Sweating for control of fever, 498 
Syphilis as cause of cerebral palsy, 

403 
of fissures at angle of mouth, 238 
congenital, 409-411 

epitrochlear glands in, 410 
inunctions of mercuric ointment 

in, 409 
iodid of potash in, 412 
later treatment of, 409-411 
rash of, 410 

40 



Syphilis contraindicating maternal 
nursing, 76 

deafness from, 444 

hereditary transmission of, 453 

hoarseness in, 410 

importance of, in family history, 39 

oil inunctions in, 144 

tardy hereditary, 411, 412 

malnutrition an evidence of, 412 

transmitted by kissing, 28 

with hemorrhagic diseases of newly 
born, 54 
Syphilitic dactylitis, 492 

periostitis of tibia, 411 
Syrups for children, 283 

upsetting digestion, 19 



Table, adjustable, for children, 538 

of weights and heights, 33 
Taenia, 227 
Taking cold, 240 
Tannalbin in ileocolitis, 214 
Tannic acid for blood in stools, 2 20 

for hemorrhoids, 230 
Tape for restraint in masturbation, 458 
Tape- worm, 228 

Tar and salicylic acid in chronic 
eczema, 425 
ointment of, in eczema, 423 
Tardy malnutrition, regimen to be fol- 
lowed, 164 
Tartar emetic, administration, 525 
in acute catarrhal laryngitis, 262 
in bronchitis, 273 
in bronchopneumonia, 283 
in faucitis, 248 
unpalatable, 525 
Tastes, 134 
Tasting, 138 
Taylor, Dr. A. S., operations for cure of 

hydrocephalus, 397 
Tea after sixth year, 138 

constipating for nursing mothers, 70 
drinking as cause of constipation, 

178 
in typhoid fever, 479 
Teeth, care of, 35 
cavities in, 35 
first tooth to appear, 35 
in rickets, 463 
loss of first, 35 

presence of, necessary for ulcerative 
stomatitis, 232 
Teething cough, 237 
Temperature, abnormal rise of, 497 
birth, 496 

by what to reduce, 283, 285 
effect of antitoxin on, in diphtheria, 

318 
in earache, 440 

in gastro-intestinal infection, 201 
in influenza, 474 



626 



INDEX 



Temperature in lobar pneumonia, 287 
in marasmus, 158 
normal, 496 
obscure elevations of, 499-501 

caused by encysted empyema, 
501 
by exercise, 499 
by intestinal infection, 501 
by otitis, 501 
by tuberculosis, 501 
by typhoid fever, 501 
of dressing-room, 241 
of sick-room, 281, 288 
periodic, in malaria, 476 
reduction of, when to reduce, 285 
room, in acute illness, 167 
subnormal, by axilla, 497 
by mouth, 497 
by rectum, 497 
in cretins, 468 
in measles, 346 
unexplained, 502 
when to interfere with, 498 
Tendon-transplantation after polio- 
myelitis, 399 
Tenesmus, 214 

Tenotomy after poliomyelitis, 399 
Tetanus antitoxin, 56 

neonatorum, 56 
Tetany, 383 _ 
Therapeutic nihilism, 18 
Thermometers in nursery, 25 
Thickened lips due to use of pacifier, 

454 
Thirst, absence of. in glycosuria, 365 
Thomas' straight-jacket, 429 
Thoracotomy for double empyema, 297 

in empyema, 296 
Thread-worm, 227 

and masturbation, 455 

as cause of enuresis, 352 

in night-terrors, 382 
Throat, examination of, 246 
Thrush, 235 
Thumb sucking, 454 

results of, 454 
Thymic asthma, 471 
Thymus, enlarged, and convulsions, 

382 
Thyroid extract, dosage, 470 
evidences of excess of, 469 
in cretinism, 469 
in obesity, 460 
Tinea circinata, 438 

tonsurans, 437 
Tomatoes as cause of urticaria, 430 

stewed, when allowed, 136 
Tongue, l3ridle, 238 

swelling of, in angioneurotic edema, 
407 

traction on, Laborde's method of 
artificial respiration, 48 

ulcer of frenum of, 238 



Tongue-tie, treatment of, 239 

Tonsillar punch for hypertrophied ton- 
sils, 252 

Tonsillitis associated with cardiac dis- 
ease, 306, 310 
with rheumatism, 485 
diagnosis versus diphtheria, 249 
difficulty in swallowing in, 250 
duration of, 249 
onset of, 248 
preceding otitis, 490 

quinsy, 253 
sprays in, 250 
symptoms of, 248, 249 
treatment of, 250-252 

Tonsils a cause of persistent deafness, 

444 
a harboring place for bacteria, 252 
hypertrophied, 252 
in epileptics, 389 
in night-terrors, 382 
removal of, for chronic bronchitis, 

274 
with asthma, 276 
Tooth picks, 35 

powder, 35 
Top-milk in cure of constipation of 

older children, 182 
Toxemia, intestinal, diagnosed as mala- 
ria, 173 
as worms, 173 
due to defective bowel evacuation, 
178 
Trachea, cast of, 328 
Tracheitis as cause of persistent cough, 

268 
Tracheotomy for foreign bodies in 

larynx, 267 
Trauma as cause of cerebral palsy, 

403 
of early convulsions, 380 
Traumatic laryngitis, 266 
Trichophyton, 438 
Truss, cleaning, 415 

in inguinal hernia, 415 

in umbilical hernia, 416 

in undescended testicle, 373 

measuring for, 415 
Tub baths for fever, 332, 498 
Tubercle bacilli in sputum of children, 

299 
Tubercular meningitis, 395 
Tuberculin, 531 

as diagnostic agent, 532 

cutaneous inoculation, 532 

ophthalmic reaction with, 299, 533 

subcutaneous inoculation, 532 
Tuberculosis as cause of obscure eleva- 
tion of temperature, 501 

climate in, 299 

contraindicating maternal nursing, 

76 
devices for collecting sputum m, 301 



INDEX 



627 



Tuberculosis fatality in young children, 

299 
frequency of occurrence, 298 
fresh air in, 299 
high proteid diet in, 299 
home treatment versus sanitarium, 

300 
importance of, in family history, 

39 
in bronchiectasis, 302 
in delicate child, 149 
in marantic cases, 158 
in nursery maids, 23 
in pertussis, 337 
infiltration of, incipient, a cause of 

persistent cough, 269 
occurrence of, 298 
of cervical lymph-glands, 452 
of hip-joint, 493 
of knee-joint, 493 
of spine, 493 
oil inunctions in, 144 
ophthalmic reaction in, 299 
physical signs of, 298 
prognosis in, 300 
tenement cases, 300 
transmitted by kissing, 28 
vaccine therapy in, 531 
von Pirquet reaction in, 299 
Tuberculous dactylitis, 492 
peritonitis, 491 

suppurative, 491 
Tumors of intestine causing intestinal 

obstruction, 222 
Turbinate bones causing nasal catarrh, 

244 
Turpentine as counterirritant, 515 
in bronchopneumonia, 282 
in thread-worms, 227 
inhalations in pertussis, 339 
Tympanites, 480 
Typhoid fever, alcohol in, 520 

antipyretic drugs in, 482 

care of mouth in, 478 

cervical adenitis in, 478 

diarrhea in, 480 

diet in, 479, 480 

disinfection of excreta in, 478 

gingivitis in, 478 

heart stimulants in, 482 

hemorrhage in, 483 

hydrotherapy in, 482 

intestinal antiseptics in, 480 

milk in, 479 

perforation in, 483 

rarity of, in children, 478 

rice in, 479 

rectal irrigations in, 482 

stools in, 480 

treatment of, 478-483 

tympanites in, 480 

vaccine therapy in, 531 

Widal reaction in, 478 



Ulceration at corner of mouth, 238 
of hard palate, 237 
of nasal septum a cause of nasal 

hemorrhage, 236 
of stomach, 195 
Ulcerative stomatitis in typhoid fever, 

478 
Umbilical cord, care of stump, 26 
hypertrophy of stump, 53 
suppuration of stump, 26 
hernia, 416 

strapping for cure of, 416 
polyp, 51 

treatment of, 51 
Umbilicus as portal of entry for infec- 
tion, 49 
Undescended testicle, 373 
Unguentum hydrargyrum in congeni- 
tal syphilis, 408 
Urea excretion, normal, and in nephri- 
tis, 361 
Uremia, convulsions in, 380 

in nephritis, 360, 363 
Urethra as portal of entry for pyogenic 
bacteria, 49 
calculi of, causing difficult micturi- 
tion, 350 
injury to, a cause of retention, 351 
Urethritis, specific, 372 
Urinary disorders, 350 
Urination difficult and painful, 350 
frequent, a precursor of bed-wetting, 

349 
Urme, 349 

acidity of, amount and frequency, 
factors influencing them, 349 

as cause of difficult urination, 
350 

enuresis, 352 

per day, 349 
continence of, 350 
devices for collecting, 350 
examination at bedside, 329 

in acute illness, 168 

in measles, 345 
in jaundice, 459 
in nephritis, 362 
in scarlatina, 359 
incontinence of, 350, 352 
specific gravity of, 349 
suppression of, in acute illness, 169 

treatment, 351 
Urotropin in acute pyelitis, 368 

in cystitis, 367 
Urticaria, 429 

due to external irritation, 430 

to internal causes, 430 
following antitoxin, 430 
giant, 407 
low diet in, 430 
treatment of, 430 
Uvula, elongation of, as cause of per- 
sistent cough, 268 



628 



INDEX 



Vaccination, age for, 506 
complications of, 507 
constitutional disturbances in, 507 
local applications, 507 
methods, 506 
shield for, 507 
tuberculin, 532 
virus for, 506 
"Vaccine therapy, 527-533 
in acne, 530 
in adenitis, 530 
in bacillus coli communis, 531 
in cerebrospinal meningitis, 531 
in empyema, 530, 531 
in erysipelas, 530 
in furunculosis, 530 
in gonococcus infection, 531 
in meningococcus infection, 531 
in osteomyelitis, 530 
in otitis media, 530, 531 
in pneumococcus infection, 531 
in pseudodiphtheria, 531 
in scarlet fever, 530 
in septicemia, 530 
in staphylococcus infection, 529 
in streptococcus infection, 530 
in styes, 530 
in suppuration, 530 

of antrum, 530 
in tuberculosis, 531 
in typhoid fever, 531 
technic, 528 
Vagina, portal of entry for pyogenic 

organisms, 49 
Vaginal discharge a deterrent to 
growth, 149 
in nursery maids, 23 
Vaginitis as cause of incontinence of 
urine, 352 
of retention of urine, 351 
Valentine's beef -juice, 125 
Vapo-cresoline inhalations in pertussis, 

339. . 
Vaporizations in diphtheria, 323 
Varicella, 346 

care of skin in, 347 
Ventilation in acute illness, 167 
Ventral hernia, 417 
Vesical calculus, 367 
Vichy, 140 

Visitors in sick-room, 288 
Visual defects in epilepsy, 389 
Voice in retropharyngeal abscess, 255 
Vomiting, 187 

after adenoids, 451 

causes for, 187 

cyclic, 495 

due to fat indigestion, 106 
to too strong food, 100 

during nursing, 72 

gavage in, 141, 142 

in congenital stenosis of pylorus, 
196, 197 



Vomiting in acute gastric indigestion, 
189 
gastro-intestinal infection, 203 
in chronic gastritis, 190 
in dilatation of the stomach, 194 
in pertussis, belt for, 342 
lavage in, 191 
of blood, 194 

persistent, a sign of peritonitis, 491 
in congenital stenosis of pylorus, 
196, 197 
projectile, in congenital stenosis of 
pylorus, 196 
with sprue, 235 
Von Jaksch, pseudoleukemic anemia 

of, 460 
Von Pirquet reaction in tuberculosis, 

299 
Vulvar douching, 374 
Vulvovaginitis, gonorrheal, 374, 375 
simple, 374 

Waking, time for, 25 

Walker-Gordon Laboratory milk for 

traveling, 122 
Walking movements, 542 
Warm air in asthma, 279 
in meningitis, 391 
pack in meningitis, 391 
Washing child's mouth, 233, 234 
in eczema, 423 
mouth in sprue, 216 
Water before nursing in fever, 139 
drinking in acute illness, 167 
function of, as a constituent of food, 

62 
in maternal nursing, 72 
in morning, 195 
in nephritis 357, 359 
pressure of, in reduction of intussus- 
ception, 223 
Water-bed in decubitus, 436 
Weaning, 76, 134 
Weighing infants, 1 50 

during nursing, 64, 73, 158 
frequency, 31 
Weight at birth, 31 
chart, 33 
initial loss of, 31 
loss of, in the mother, contraindicat- 

ing nursing, 76 
normal amount of gain in, 32 
of girls compared to boys, 32 
stationary, a premonitory sign of 
malnutrition, 150 
in maternal nursing, 72 
Well-water in country, 514 
Wet compresses for laryngitis, 267 
dressings of bichloride, 49 

of boric acid, 49 
sweeping in measles, 346 
Wet-nurse after gastro-intestinal infec- 
tion, 206 



INDKX 



629 



Wet-nurse, age of, 80 

diet of, 70 

examination of, 80 

in anemia of the bottle-fed, 461 

in difficult feeding cases, 112 

in gastritis, chronic, 190 

in marasmus, 157 

in premature infants, 47 

in stenosis of the pylorus, 197 

in tetany, 384 

selection of, 80 
Wheat crackers as cause of constipa- 
tion, 182 

jelly, formula for preparing, 129 
Wheatena, when allowed, 136 
Whey, 161 

formula for preparing, 130 

in difficult feeding, 112 

in premature infants, 47 

mixtures, 107 
Whisky, 291. See also Alcohol. 

in erysipelas, 484 
White bread as cause of constipation, 
182 

precipitate ointment in ringworm of 
scalp, 437 



Whooping-cough. See also Pertussis. 

Widal reaction, 478 

Window-board, 25, 44, 59, 153, 271, 
281, 288 

Wine after sixth year, 138 

Winter diarrhea predisposing to sum- 
mer diarrhea, 171, 198 

Woolen clothing after nephritis, 361 

Worms as cause of convulsions, 380 
as sign of intestinal toxemia, 173 
symptoms of, 226 
treatment of, 228 

Worry, bad effect on lactation, 76 

Written directions, 39 

Yerba SANTA a menstruum for quinin, 

526 
Yerbazine a vehicle for quinin, 340, 

526 

Zinc oxid in eczema, 423, 424 
ointment in eczema, 425 
in intertrigo, 424 
Zwieback, 479 

when allowed, 135-137 



SAUNDERS' BOOKS 



on 



Nervous and Mental 
Diseases, Children, 
Hygiene, Nursing, and 
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W. B. SAUNDERS COMPANY 

925 WALNUT STREET PHILADELPHIA 

9. HENRIETTA STREET COVENT GARDEN, LONDON 

THE SUPERIORITY OF SAUNDERS* TEXT=BOOK 

In a recent series of articles entitled 

"WHAT ARE THE BEST MEDICAL TEXT-BOOKS?" 

a well known medical journal compiled a tabulation of the 
text-books recommended in those schools which are members 
of the American Association of Medical Colleges. The text- 
books were divided into twenty (20) subjects and under each 
subject was given a list of the various books with the number 
of times each book is recommended. Saunders' books head 
ten (10) of the twenty (20) subjects, the largest number head- 
ed by any other publisher being three (3). In other words, 
Saunders' books lead in as many subjects as the books of all the other 
publishers combined. 

A Complete Catalogue of Our Publications will be Sent upon request 



SAUNDERS' BOOKS ON 



Church and Peterson's 
Nervous and Mental Diseases 



Nervous and Mental Diseases. By Archibald Church, M. D., 
Professor of Nervous and Mental Diseases and Medical Jurisprudence, 
Northwestern University Medical School, Chicago; and Fkederick 
Peterson, M.D., President New York State Commission en Lunacy; 
Professor of Psychiatry at the College of Physicians and Surgeons, 
N. Y. Handsome octavo, 944 pages; 341 illustrations. Cloth, ;^5.0o 
net; Sheep or Half Morocco, ;^6.5o net. 

RECENTLY ISSUED— NEW (6th) EDITION 

This work has met with a most favorable reception from the profession at 
large. It fills a distinct want in medical literature, and is unique in that it 
furnishes in one volume practical treatises on the two great subjects of neurology 
and psychiatry. In preparing this edition the work has been thoroughly revised 
and new articles on Psychasthenia and Psychotherapy added. The recent views 
in regard to the motor area of the Rolandic region have necessitated the rewriting 
of the chapter pertaining to the related subjects. A number of new illustrations 
have also been added. A feature of much value is the very full and complete 
review of recent problems of psychiatry. 



OPINIONS OF THE MEDICAL PRESS 



American Journal of the Medical Sciences 

" This edition has been revised, new illustrations added, and some new matter, and really 
is two books. . . . The descriptions of disease are clear, directions as to treatment definite, 
and disputed matters and theories are omitted. Altogether it is a most useful text-book." 

Journal of Nervous and Mental Diseases 

"The best text-book exposition of this subject of our day for the busy practitioner. . . . 
The chapter on idiocy and imbecihty is undoubtedly the best that has been given us in any 
work of recent date upon mental diseases. The photographic illustrations of this part of Dr. 
Peterson's work leave nothing to be desired." 

New York Medical Journal 

"To be clear, brief, and thorough, and at the same time authoritative, are merits that 
easure popularity. The medical student and practitioner will find in this volume a ready and 
reliable resource." 



DISEASES OF CHILDREN, 



KerrV Diagnostics qf 
Diseases qf Children 

Diagnostics of the Diseases of Children. By LeGrand Kerr, 
M. D., Professor of Diseases of Children, Brooklyn Postgraduate Med- 
ical School, Brooklyn. Octavo of 542 pages, fully illustrated. Cloth, 
;^5.oo net; Half Morocco, ^6.50 net. 

FOR THE PRACTITIONER 

Dr. Kerr' s work differs from all others on the diagnosis of diseases of children 
in that the objective symptoms are particularly emphasized. The constant aim 
throughout has been to render a correct diagnosis as early in the course of the 
disease as possible, and for this reason differential diagnosis is presented from 
the very earliest symptoms. The many original illustrations wfll be found 
helpful. 

New York State Journal of Medicine 

" The illustrations are excellent and numerous. It will meet the needs of the great mass 
of physicians who treat the diseases of infancy and childhood." 

Kerley's Treatment qf 
Diseases qf Children 

Treatment of the Diseases of Children. By Charles Gilmore 
Kerley, M. D., Professor of Diseases of Children, New York Polyclinic 
School and Hospital. Octavo of 597 pages, illustrated. Cloth, $5.00 
net ; Half Morocco, $6.50 net. 

THE PRACTITIONER'S PEDIATRICS 

This work has been prepared for the physician engaged in general practice. 
The author presents all the modern methods of management and treatmejit in 
greater detail than a7iy other work on the subject heretofore published. The 
methods suggested are the results of actual personal experience, extending over a 
number of years of hospital and private practice. There is an excellent illus- 
trated chapter on Gymnastic Therapeutics. 

The British Medical Journal 

" Dr. Kerley's book is one of the best on the subject that has come under our notice. All 
through it shows evidence of ripe experience and sound judgment." 



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GET /|k • THE NEW 

THE BEST i\ m © n C 8111 STANDARD 

Illtsstrated Dictionary 

The New (4th) Edition 



The American Hlustrated Medical Dictionary. A new and com- 
plete dictionary of the terms used in Medicine, Surgery, Dentistry, 
Pharmacy, Chemistry, and kindred branches ; with over lOO new and 
elaborate tables and many handsome illustrations. By W. A. Newman 
Borland, M. D., Editor of " The American Pocket Medical Diction- 
ary." Large octavo, nearly 850 pages, bound in full flexible leather. 
Price, $4.50 net; with thumb index, ^5.00 net. 

Gives a Maximum Amount of Matter in a Minimum Space, and at the Lowest 

Possible Cost 

WITH 2000 NEW TERMS 

The immediate success of this work is due to the special features that distin- 
guish it from other books of its kind. It gives a maximum of matter in a mini- 
mum space and at the lowest possible cost. Though it is practically unabridged, 
yet by the use of thin bible paper and flexible morocco binding it is only i ^ 
inches thick. The, result is a truly luxurious specimen of book-making. In this 
new edition the book has been thoroughly revised, and upward of two thousand 
new terms that have appeared in recent medical literature have been added, thus 
bringing the book absolutely up to date. The book contains hundreds cf terms 
not to be found in any other dictionary, over loo original tables, and many hand- 
some illustrations, a number in colors. 



PERSONAL OPINIONS 



Howard A. Kelly. M. D., 

Professor of Gynecology, Johns Hopkins University , Baltimore. 

" Dr. Dorland's dictionary is admirable. It is so well gotten up and of such convenient 
size. No errors have been found in my use of it." 

J. Collins Warren, M.D., LL.D., F.R.C.S. (Hon.) 

Professor of Surgery, Harvard Medical School. 

" I regard it as a valuable aid to my medical literary work. It is very complete and of 
convenient size to handle comfortably. I use it in preference to any other." 



NURShYG. 



Macfarlane's Gynecology for Nurses just issued 

A Reference Hand-Book of Gynecology for Nurses. By Cath- 
arine Macfarlane, M. D., Gynecologist to the Woman's Hospital of 
Philadelphia. 32mo of 150 pages, with 70 illustrations. Flexible 
leather, $1.25 net. 

This new work, uniform in size and style with Beck's Reference Hand- 
Book, is a complete treatise on gynecology for the nurse. The illustrations 
are all original and are unusually instructive. Nurses will find this book — 
of a size to fit the pocket — a valuable companion. 

Aikens* Primary Studies for Nurses Ready in February 

Primary Studies for Nurses : A Text-Book for First-year Pupil 
Nurses. By Charlotte A. Aikens, late Director of Sibley Memorial 
Hospital, Washington, D. C. 12 mo of 450 pages, illustrated. 

This work brings together in concise form well-rounded courses of lessons in 
anatomy, physiology, hygiene, bacteriology, therapeutics and materia medica, 
dietetics, and invalid cookery — in fact, all subjects which, with practical nurs- 
ing technic, constitute the primary studies in a nursing course. The matter 
has been condensed as much as clearness would permit, and arranged in 
such a way that it can be quickly and easily grasped by the student. 

De Lee's Obstetrics for Nurses Nf^Tsd^EdS^n 

Obstetrics for Nurses. By Joseph B. DeLee, M. D., Professor of 
Obstetrics in the Northwestern University Medical School. i2mo vol- 
ume of 512 pages, fully illustrated. Cloth, $2.50 net. 

J. Clifton Edgar, M. D., 

Professor of Obstetrics and Clinical Midwifery, Cornell Medical School, N. Y. 

" It is far-and-away the best that has come to my notice, and I shall take great pleasure in recom- 
mending it to my nurses and students as well." 

Davis' Obstetric Nursing Nel^'^adJ^ES 

Obstetric and Gynecologic Nursing. By Edward P. Davis, A. M., 
M. D. , Professor of Obstetrics, Jefferson Medical College and Philadel- 
phia Polyclinic. i2mo of 436 pages, illustrated. Buckram, ^1.75 net. 

The Lancet, London 

" Not only nurses, but even newly qualified medical men, would learn a great deal by a perusal of 
this book. It is written in a clear and pleasant style, and is a work we can recommend." 

Beck's Hand-Book for Nurses N^rtldfEdtu^n 

A Reference Hand-Book for Nurses. By Amanda K. Beck, of 
Chicago, 111. 32mo of 200 pages. Flexible leather, $1.25 net. 

This little book contains information upon every question that comes to a 
nurse in her daily work, and embraces all the information that she requires 
to carry out any directions given by the physician. 

Boston Medical and Surgical Journal 

" Must be regarded as an extremely useful book, not only for nurses, but for physicians." 



SAUNDERS' BOOKS ON 



Hoxie's Medicine for Nurses Recently issued 

Practice of Medicine for Nurses. A Text-Book for Nurses and Students 
of Domestic Science, and a Hand-Book for All Those Who Care for the Sick. 
By George Howard Hoxie, M. D., Professor of Internal Medicine, Uni- 
versity of Kansas. With a Chapter on Technic of Nursing by Pearl L. 
Laptad, Principal of the Training School for Nurses, University of Kansas. 
i2mo of 284 pages, illustrated. Cloth, $1.50 net. 

This work is truly a practice of medicine for the nurse, enabling her to recognize any 
signs and changes that may occur between visits of the physician, and, if necessary, to 
combat them until the physician's arrival. This information the author presents in a way 
most acceptable, particularly emphasizing the nurse's part. There are also special chapters 
on the diseases of infancy and childhood, diseases of the eye, ear, nose, and throat, 
venereal diseases, nervous and mental diseases, surgical nursing, nursing in skin diseases, 
emergency measures, and the care and management of the sick-room and the patient. 

McCombs' Diseases of Children for Nurses ^is^sued 

Diseases of Cliildren for Nurses. By Robert S. McCombs, M. D., 
Instructor of Nurses at the Children's Hospital of Philadelphia. i2mo of 
430 pages, illustrated. Cloth, ^2.00 net. 

Dr. McCombs' experience in lecturing to nurses has enabled him to ^v\^2i€\z& just those 
points that nurses most need to know. The nursing side has been written by head nurses, 
especially praiseworthy being the work of Miss Jennie Manly. 

National Hospital Record 

" We have needed a good work on children's diseases adapted for nurses' use, and this 
volume admirably fills the want." 

Wilson's Obstetric Nursing Recently issued 

A Reference Hand=Book of Obstetric Nursing. By W. Reynolds 
Wilson, M. D., Visiting Physician to the Philadelphia Lying-in Charity. 
32mo of 258 pages, illustrated. Flexible leather, $1.25 net. 

Dr. Wilson's work discusses the subject of obstetrics entirely from the nurse's point of 
view, presenting in detail everything connected with pregnancy and labor and their man- 
agement. The text is copiously illustrated. 

American Journal of Obstetrics 

" Every page emphasizes the nurse's relation to the case." 

Aikens* Training-School Methods Recently issued 

Hospital Training= School Methods and the Head Nurse. By Char- 
LOTTE A. AiKENS, Late Director of Sibley Memorial Hospital, Washington, 
D. C. i2mo of 267 pages. Cloth, ^1.50 net. 

This new work suggests plans that have been tested personally. It tells the head nurse 
how to teach ; it tells what should be taught the nurse and how much. 

Trained Nurse and Hospital Review 

" There is not a chapter in the book that does not contain valuable suggestions." 



NURSING. 



Golebiewski and Bailey's 
Accident Diseases 



Atlas and Epitome of Diseases Caused by Accidents. By Dr. Ed. 

Golebiewski, of Berlin. Edited, with additions, by Pearce Bailey, 
M.D., Consulting Neurologist to St. Luke's Hospital, New York. 
With 71 colored illustrations on 40 plates, 143 text-illustrations, and 
549 pages of text. Cloth, ;^4.oo net. In Saunders' Hand- Atlas 
Series. 

This work contains a full and scientific treatment of the subject of accident 
injury ; the functional disability caused thereby ; the medicolegal questions in- 
volved, and the amount of indemnity justified in given cases. The work is 
indispensable to every physician who sees cases of injury due to accidents, to 
advanced students, to surgeons, and, on account of its illustrations and statistical 
data, it is none the less useful to accident-insurance organizations. 

The Medical Record, New York 

" This volume is upon an important and only recently systematized subject, which is grow- 
ing in extent all the time. The pictorial part of the book is very satisfactory." 

Stoney's 
Materia Medica for Nurses 



Practical Materia Medica for Nurses, with an Appendix containing 
Poisons and their Antidotes, with Poison-Emergencies ; Mineral Waters ; 
Weights and Measures ; Dose-List, and a Glossary of the Terms used 
in Materia Medica and Therapeutics. By Emily M. A. Stoney, of the 
Carney Hospital, South Boston. i2mo of 300 pages. Cloth, ^1.50 net. 

THE NEW (3d) EDITION 

In making the revision for this new third edition, all the newer drugs have 
been introduced and fully discussed. The consideration of the drugs includes 
their sources and composition, their various preparations, physiologic actions, 
directions for administering, and the symptoms and treatment of poisoning. 

Journal of the Americsoi Medical Association 

" So fe.r as we can see, it contains everything that a nurse ought to know in regard to drugs. 
As a refer«Hce-book for nurses it will without question be very useful." 



SAUNDERS' BOOKS ON 



Stoney's Nursing 



Practical Points in Nursing : for Nurses in Private Practice. By 
Emily M. A. Stoney, Superintendent of the Training School for Nurses 
at the Carney Hospital, South Boston, Mass. 466 pages, fully illus- 
trated. Cloth, ^1.75 net. 

THIRD EDITION. THOROUGHLY REVISED 

In this volume the author explains the entire range of private nursing as dis- 
tinguished from hospital nursing, and the nurse is instructed how best to meet the 
various emergencies of medical and surgical cases when distant from medical or 
surgical aid or when thrown on her own resources. An especially valuable feature 
will be found in the directions how to improvise everything ordinarily needed in the 
sick-room. 

The Lancet, London 

"A very complete exposition of practical nursing in its various branches, including obstetric 
and gynecologic nursing. The instructions given are full of useful detail." 



Stoney's Technic for Nurses 

Bacteriology and Surgical Technic for Nurses. By Emily M. A. 
Stoney, Superintendent at Carney Hospital, South Boston. Revised 
by Frederic R. Griffith, M. D., Surgeon, of New York. i2mo, 
278 pages, illustrated. Cloth, ;^i.50 net. 

THE NEW (2d) EDITION 
Trained Nurse and Hospital Review 

" These subjects are treated most accurately and up to date, without the superfluous reading 
w^hich is so often employed, . . . Nurses will find this book of the greatest value both during 
their hospital course and in private practice." 

Spratling on Epilepsy 

Epilepsy and Its Treatment. By William P. Spratling, M. D., 
Medical Superintendent of the Craig Colony for Epileptics, Sonyea, 
New York. Octavo of 522 pages, fully illustrated. Cloth, ^4.00 net. 

The Lancet, London 

" Dr. Spratling's work is written throughout in a clear and readable style. . . . The work 
is a mine of information on the whole subject of epilepsy and its treatment." 



NURSIXG AND CHILDREN. 



Paul's Fever Nursing 

Nursing ix the Acute Infectious Fevers. By George P. Paul, 
]M.D., Assistant Visiting Physician to the Samaritan Hospital, Troy, N. Y. 
i2mo of 200 pages. Cloth, §1.00 net. 

Dr. Paul has taken great pains in the presentation of the care and management of each 
fever. The book treats of fevers in general, then each fever is discussed individually, and 
the latter part of the book deals with practical procedures and valuable information.' 

The London Lancet 

■' The book is an excellent one and will be of value to those for whom it is intended. 
It is well arranged, the text is clear and full, and the illustrations are good." 

Paul's Materia Medica for Nurses 

Materia Medica for Nurses. By George P. Paul, M.D., Assistant 
Visiting Physician to the Samaritan Hospital, Troy. i2mo of 240 pages. 
Cloth, ;^i.5o net. 

Dr. Paul arranges the physiologic actions of the drugs according to the action of the 
drug and not the organ acted upon. An important section is that on pretoxic signs, 
giving the warnings of the full action or the beginning toxic effects of the drug, which, 
if heeded, may prevent many cases of drug poisoning. 

The Medical Record, New York 

"This volume will be of real help to nurses; the material is well selected and well 
arranged, and the book is as readable as it is useful." 

Pyle's Personal Hygiene The New (3d) Edition 

A Manual of Personal Hygiene : Proper Living upon a Physiologic 
Basis. By Eminent Specialists. Edited by Walter L. Pyle, A.M., 
M.D., Assistant Surgeon to "Wills Eye Hospital, Philadelphia. Octavo 
volume of 451 pages, fully illustrated. Cloth, $1.50 net. 

To this new edition there have been added, and fully illustrated, chapters on Domestic 
Hygiene and Home Gymnastics, besides an appendix containing methods of Hydro- 
therapy, Mechanotherapy, and First Aid Measures. There is also a Glossary of the 
medical terms used. 

Boston Medical and Surgical Journal 

" The work has been excellently done, there is no undue repetition, and the writers 
have succeeded unusually well in presenting facts of practical significance based on sound 
knowledge." 

Galbraith's Four Epochs of Woman's Life second Edition 

The Four Epochs of Woman's Life. By Anna ^I. Galbraith, 
M.D. With an Introductoiy Note by John H. Musser, :M.D., Univer- 
sity of Pennsylvania. i2mo of 247 pages. Cloth, Si. 50 net. 
Birmingham Medical Review 

"We do not as a rule care for medical books written for the instruction of the pubhc ; 
but we must admit that the advice in Dr. Galbraith's work is in the main wise and whole- 
some." 

Starr on Children second Edition 

American Text-Book of Diseases of Children. Edited by Louis 
Starr, M.D., assisted by Thompson S. Westcott, ^NI.D. Octavo, 1244 
pages, illustrated. Cloth, S7.00 net: Half jMorocco, $8.50 net. 



SAUNDERS' BOOKS ON 



Register's Fever Nursing 

A Text-Book on Practical Fever Nursing. By Edward C. 
R.EGISTER, M. D., Professor of the Practice of Medicine in the North 
Carolina Medical College. i2mo of 352 pages. Cloth, $2.50 net. 

The work completely covers the field of practical fever nursing. The illustrations show 
the nurse how to perform those measures that come within her province. 

Trained Nurse and Hospital Review 

" Nurses will find this book of great value in this practical branch of their work." 

Hecker, Trumpp, and Abt on Children 

Atlas and Epitome of Diseases of Children. By Dr. R. Hecker 
and Dr. J. Trumpp, of Munich. Edited, with additions, by Isaac A. 
Abt, M.D., Assistant Professor of Diseases of Children, Rush Medical 
College, Chicago. With 48 colored plates, 144 text-cuts, and 453 pages 
of text. Cloth, ^5.00 net. 

The many excellent lithographic plates represent cases seen in the authors' clinics, and 
have been selected with great care, keeping constantly in mind the practical needs of the 
general practitioner. These beautiful pictures are so true to nature that their study is 
equivalent to actual clinical observation. The editor, Dr. Isaac A. Abt, has added all new 
methods of treatment. 

Johns Hopkins Hospital Bulletin 

" The entire field has been covered. With the excellent plates, it will be found of real 
value to both students and practitioners." 

Lewis' Anatomy and Physiology 

Anatomy and Physiology for Nurses. By LeRoy Lewis, M.D., 
Surgeon to and Lecturer on Anatomy and Physiology for Nurses at the 
Lewis Hospital, Bay City, Michigan. i2mo of 347 pages, with 146 
illustrations. Cloth, ^1.75 net. 

A demand for such a work as this, treating the subjects from the mirses' poi7tt of view, 
has long existed. Dr. Lewis has based the plan and scope of this work on the methods 
employed by him in teaching these branches, making the text unusually simple and clear. 

The Nurses Journal of the Pacific Coast 

" It is not in any sense rudimentary, but comprehensive in its treatment of the subjects 
in hand. The application of the knowledge of anatomy in the care of the patient is 
emphasized." 

Friedenwald and Ruhrah's Dietetics 

Dietetics for Nurses. By Julius Friedenwald, M. D., Professor 
of Diseases of the Stomach, and John Ruhrah, M. D., Professor of 
Diseases of Children, College of Physicians and Surgeons, Baltimore. 
i2mo volume of 365 pages. Cloth, ^1.50 net. 

This work has been prepared to meet the needs of the nurse, both in the training 
school and after graduation. It aims to give the essentials of dietetics, considering briefly 
the physiology of digestion and the various classes of foods and the part they play in 
nutrition. 

American Journal of Nursing 

" It is exactly the book for which nurses and others have long and vainly sought. A 
simple manual of dietetics, which does not turn into a cook-book at the end of the first 
or second chapter. 



INSANITY AND HYGIENE. 



Brower and Bannister 
on Insanity 

A Practical Manual of Insanity. For the Student and General 
Practitioner. By Daniel R. Brower, A.M., M.D., LL. D., Professor 
of Nervous and Mental Diseases in Rush Medical College, in affiliation 
with the University of Chicago ; and Henry M. Bannister, A. M., 
M. D., formerly Senior Assistant Physician, Illinois Eastern Plospital 
for the Insane. Handsome octavo of 426 pages, with a number of 
full-page inserts. Cloth, ^3.00 net. 

FOR STUDENT AND PRACTITIONER 

This work, intended for the student and general practitioner, is an intelligible, 
up-to-date exposition of the leading facts of psychiatry, and will be found of in- 
valuable service, especially to the busy practitioner unable to yield the time for a 
more exhaustive study. The work has been rendered more practical by omitting 
■elaborate case records and pathologic details, as well as discussions of speculative 
and controversial questions. 

American Medicine 

'■ Commends itself for lucid expression in clear-cut English, so essential to the student in 
any department of medicine. . . . Treatment is one of the best features of the book, and for 
this aspect is especially commended to general practitioners." 

Bergey's Hygiene 

The Principles of Hygiene: A Practical Manual for Students, 
Physicians, and Health Officers. By D. H. Bergey, A. M., ?>I. D., 
Assistant Professor of Bacteriology in the University of Pennsylvania. 
Octavo volume of 536 pages, illustrated. Cloth, 33.00 net. 

SECOND REVISED EDITION 

This book is intended to meet the needs of students of medicine in the 
acquirement of a knowledge of those principles upon which modern hygienic 
practises are based, and to aid physicians and health officers in familiarizing 
themselves with the advances made in hygiene and sanitation in recent years. 
This new second edition has been very carefully revised, and much new matter 
added, so as to include the most recent advancements. 

Buffalo Medical Journal 

" It will be found of value to the practitioner of medicine and the practical sanitarian ; and 
students of architecture, who need to consider problems of heating, lighting, ventilation, water 
supply, and sewage disposal, may consult it with profit." 



12 SAUNDERS' BOOKS ON 

Friihwald and WestcottV 
Diseases of Children 



Diseases of Children. A Practical Reference Book for Students 
and Practitioners. By Professor Dr. Ferdinand Frijhwald, of 
Vienna. Edited, with additions, by Thompson S Westcott, M. D., 
Associate in Diseases of Children, University of Pennsylvania. Octavo 
volume of 533 pages, containing 176 illustrations. Cloth, ^4.50 net. 

ARRANGED ALPHABETICALLY 

This work represents the author's twenty years' experience, and is intended 
as a practical reference work for the student and practitioner. With this refer- 
ence feature in view, the individual diseases have been arranged alphabetically. 
The prophylactic, therapeutic, and dietetic treatments are elaborately discussed. 
The practical value of the book has been considerably enhanced by the many 
excellent illu'strations. 
C. H. Bartley, M. D., 

Professor of Pediatrics, Chemistry , and Toxicology, Long Island College Hospital, New York. 
"It is a new idea, wiiich ought to become popular because of the alphabetic arrangement. 
its title expresses just what it is — a ready reference hand-book." 



Ruhrah's 
Diseases of Children 

A Manual of Diseases of Children. By John Ruhrah, M. D.„ 
Professor of Diseases of Children, College of Physicians and Surgeons, 
Baltimore. i2mo of 425 pages, fully illustrated„ Flexible leather, 
$2.00 net. 

THE NEW (2d) EDITION 

In revising this work for the second edition Dr. Ruhrah has carefully 
incorporated all the latest knowledge on the subject. All the important facts 
are given concisely and explicitly, the therapeutics of infancy and childhood 
being outlined very carefully and clearly. There are also directions for dosage 
and prescribing, and many useful prescriptions are included. The entire work 
is amply illustrated with practical illustrations. A valuable aid consists in the 
references to pediatric literature. 

American Journal of the Medical Sciences 

" Treatment has been satisfactorily covered, being quite in accord with the best teaching, 
yet withal broadly general and free from stock prescriptions." 



CHILDREN AND HYGIENE. 13 

Griffith's Care of the Baby 

The Care of the Baby. By J. P. Cromer Griffith, M. D., Clinical 
Professor of Diseases of Children, University of Penn. ; Physician to the 
Children's Hospital, Phila. i2mo, 455 pp. Illustrated. Cloth, $1.50 net. 

THE NEW (4thj EDITION 

The author has endeavored to furnish a reliable guide for mothers. He has 
made his statements plain and easily understood, in the hope that the volume 
may be of service not only to mothers and nurses, but also to students and practi- 
tioners whose opportunities for observing children have been limited. 

New York Medical Journal 

"We are confident if this little work could find its way into the hands of every trained 
nurse and of every mother, infant mortality would be lessened by at least fifty per cent." 

Crothers' Morphinism 

Morphinism and Narcomania from Opium, Cocain, Ether, Chloral, 
Chloroform, and other Narcotic Drugs ; also the Etiology, Treatment, 
and Medicolegal Relations. By T. D. Crothers, M. D., Superintendent 
of Walnut Lodge Hospital, Hartford, Conn. Handsome i2mo of 351 
pages. Cloth, ;^2.oo net. 

The Lancet, London 

"An excellent account of the various causes, symptoms, and stages of morphinism, the 
discussion being throughout illuminated by an abundance effects of clinical, psychological, and 
social interest." 

Abbott's Transmissible Diseases 

The Hygiene of Transmissible Diseases : Their Causation, Modes 
of Dissemination, and Methods q{ Prevention. By A. C. Abbott, M. D., 
Professor of Hygiene and Bacteriology, University of Pennsylvania. 
Octavo, 351 pages, with numerous illustrations. Cloth, ,$2.50 net. 

SECOND REVISED EDITION 

During the interval that has elapsed since the appearance of the first edition 
investigations upon the modes of dissemination of certain of the specific infections 
have been very active. The sections on Malaria, Yellow Fever, Plague, Filariasis, 
Dysentery, and Tuberculosis have been both revised and enlarged. 

The Lancet, London 

" We heartily commend the book as a concise and trustworthy guide in the subject with 
which it deals, and we sincerelv congratulate Professor Abbott." 



14 SAUNDERS' BOOKS ON 



Peterson and Haines' 
Legal Medicine €? Toxicology 



A Text=Book of Legal Medicine and Toxicology. Edited by 

Frederick Peterson, M. D., Professor of Psychiatry in the College 
of Physicians and Surgeons, New York ; and Walter S. Haines, 
M. D., Professor of Chemistry, Pharmacy, and Toxicology, Rush 
Medical College, in affiliation with the University of Chicago. Two 
imperial octavo volumes of about 750 pages each, fully illustrated. 
Per volume: Cloth, ^^5.00 net; Sheep or Half Morocco, ;^6.5o net 
Sold by Subscription. 

IN TWO VOLUMES— BOTH VOLUMES NOW READY 

The object of the present work is to give to the medical and legal professions 
a comprehensive survey of forensic medicine and toxicology in moderate compass. 
This, it is believed, has not been done in any other recent work in English. Under 
" Expert Evidence " not only is advice given to medical experts, but suggestions 
are also made to attorneys as to the best methods of obtaining the desired infor- 
mation from the witness. An interestmg and important chapter is that on ' ' The 
Destruction and Attempted Destruction of the Human Body by Fire and Chemi- 
cals." A chapter not usually found m works on legal medicine is that on "The 
Medicolegal Relations of the X-Rays. ' This section will be found of unusual im- 
portance. The responsibility of pharmacists in the compounding of prescriptions, 
in the selling of poisons, in substituting drugs other than those prescribed, etc., 
furnishes a chapter of the greatest interest to every one concerned with questions 
■of medical jurisprudence. Also mcluded in the work is the enumeration of the 
laws of the various states relating to the commitment and retention of the insane. 



OPINIONS OF THE MEDICAL PRESS 



Medical News, New York 

" It not only fills a need from the standpoint of timeliness, but it also sets a standard of 
what a text-book on Legal Medicine and Toxicology should be." 

Columbia Law Review 

" For practitioners in criminal law and for those in medicine who are called upon to give 
court testimony in all its various forms ... it is extremely valuable." 

Pennsylvania Medical Journal 

" If the excellence of this volume is equaled by the second, the work will easily take rank 
as the standard text-book on Legal Medicine and Toxicology." 



LEGAL MEDICINE. 



Draper's Leg'al Medicine 

A Text=Book of Legal Medicine. By Frank Winthrop Draper, 
A. M., M. D., Professor of Legal Medicine in Harvard University, Bos- 
ton; Medical Examiner of the County of Suffolk, Massachusetts, etc. Octavo 
volume of 573 pages, fully illustrated. Cloth, I4.00 net; Half Morocco, 
^5.50 net. 

Hon. Olin Bryan, LL. B. 

P?-ofessor of Medical Jurisprudence , Baltimore Medical College 

" A careful reading of Draper's Legal Medicine convinces me of the excellent character 
of the work. It is comprehensive, thorough, and must, of a necessity, prove a splendid 
acquisition to the libraries of those who are interested in medical jurisprudence." 

Chapman's Medical Jurisprudence Third Edition 

Medical Jurisprudence, Insanity, and Toxicology. By Henry C. 
Chapman, M. D., Professor of Institutes of Medicine and Medical Juris- 
prudence in Jefferson Medical College, Philadelphia. i2mo of 329 pages, 
fully illustrated. Cloth, $1.75 net. 

Medical Record, New York 

" The manual is essentially practical, and is a useful guide for the general practitioner, 
besides possessing literary merit." 

Hofmann and Peterson's Legal Medicine Hand-Atiases 

Atlas of Legal Medicine. By Dr. E. von Hofmann, of Vienna. 
Edited by Frederick Peterson, M. D., Professor of Psychiatry in the 
College of Physicians and Surgeons, New York. With 120 colored figures 
on 56 plates and 193 half-tone illustrations. Cloth, ^3.50 net. 

The Practitioner, London 

" The illustrations appear to be the best that have ever been published in connection 
with this department of medicine, and they cannot fail to be useful alike to the medical 
jurist and to the student of forensic medicine." 

Jakob and Fisher's Nervous System 

and its Diseases in Saunders* Hand-Atlases 

Atlas and Epitome of the Nervous System and its Diseases. By 

Professor Dr. Chr. Jakob, of Erlangen. From the Second Revised 
German Editio7i. Edited, with additions, by Edward D. Fisher, M. D., 
Professor of Diseases of the Nervous System, University and Bellevue 
Hospital Medical College, New York. With 83 plates and copious text. 
Cloth, $3.50 net. 

Philadelphia Medical Journal 

" We know of no one work of anything like equal size which covers this important and 
complicated field with the clearness and scientific fidelity of this hand-atlas." 



i6 SAUNDERS' BOOKS ON CHILDREN. 

American Pocket Dictionary Fifth Edition. Revised 

American Pocket Medical Dictionary. Edited by W. A. New- 
man Borland, M. D., Assistant Obstetrician to the Hospital of the 
University of Pennsylvania. Containing the pronunciation and defini- 
tion of the principal words used in medicine and kindred sciences, with 
64 extensive tables. Handsomely bound in flexible leather, with gold 
edges, ^i.oo net; with patent thumb index, ^1.25 net. 

" I can recommend it to our students without reserve." — J. H. HOLLAND, M. D., Dean 
of the Jefferson Medical College, Philadelphia. 

Morrow's Immediate Care of Injured 

Lmmediate Care of the Injured. By Albert S. Morrow, ]M. I)., 
Attending Surgeon to the New York City Hospital for the Aged and 
Infirm. Octavo of 340 pages, with 238 illustrations. Cloth, ^2.50 net. 

Dr. Morrow's book on emergency procedures is written in a definite and decisive style, 
the reader being told just what to do in every emergency. It is a practical book for every 
day use, and the large number of exxellent illustrations can not but make the treatment to 
be pursued in any case clear and intelligible. Physicians and nurses will find it indispensible. 

Powell's Diseases of Children Third Edition, Revised 

Essentials of the Diseases of Children. By William M. Powell, 
M. D. Revised by Alfred Hand, Jr., A. B., M. D., Dispensary 
Physician and Pathologist to the Children's Hospital, Philadelphia. 
i2mo volume of 259 pages. Cloth, |i.oo net. In Saunders' 
Questio7i- Compend Series. 

Shaw on Nervous Diseases and Insanity Fourth Edition 

Essentials of Nervous Diseases and Insanity : Their Symptoms 
and Treatment. A Manual for Students and Practitioners. By the late 
John C. Shaw, M. D., Clinical Professor of Diseases of the Mind and 
Nervous System, Long Island College Hospital, New York. i2mo of 
204 pages, illustrated. Cloth, ^i.oo net. In Saunders' Question- Com- 
peJid Series. 

" Clearly and intelligently written ; we have noted few inaccuracies and several sug- 
gestive points. Some affections unmentioned in many of the large text-books are noted.*" 
— Bosto7i Medical and Stirgical Journal. 

Starr's Diets for Infants and Children 

Diets for Infants and Children in Health and in Disease. By 
Louis Starr, M. D., Consulting Pediatrist to the Maternity Hospital, 
Philadelphia. 230 blanks (pocket-book size). Bound in flexible leather, 
^1.25 net. 

Grafstrom's Mechano-Therapy second Revised Edition 

A Text-book of Mechano-therapy (Massage and Medical Gymnas- 
tics). By Axel V. Grafstrom, B. Sc, M. D., Attending Physician to 
the Gustavus Adolphus Orphange, Jamestown, New York. i2mo, 200 
pages, illustrated. Cloth, $1.25 net. 



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